Provider Demographics
NPI:1437344504
Name:TRAVIS, MARLENE J (LMP)
Entity Type:Individual
Prefix:
First Name:MARLENE
Middle Name:J
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:305 N MAPLE ST
Mailing Address - Street 2:
Mailing Address - City:ELLENSBURG
Mailing Address - State:WA
Mailing Address - Zip Code:98926-3574
Mailing Address - Country:US
Mailing Address - Phone:509-929-3636
Mailing Address - Fax:
Practice Address - Street 1:305 N MAPLE ST
Practice Address - Street 2:
Practice Address - City:ELLENSBURG
Practice Address - State:WA
Practice Address - Zip Code:98926-3574
Practice Address - Country:US
Practice Address - Phone:509-929-3636
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-09-11
Last Update Date:2007-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA00023298174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist