Provider Demographics
NPI:1568174878
Name:TRAVIS, KIMBERLY COOPER (RPHT)
Entity Type:Individual
Prefix:MRS
First Name:KIMBERLY
Middle Name:COOPER
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:RPHT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:613 OPP REYNOLDS RD
Mailing Address - Street 2:
Mailing Address - City:HAZEL GREEN
Mailing Address - State:AL
Mailing Address - Zip Code:35750-8237
Mailing Address - Country:US
Mailing Address - Phone:256-656-2061
Mailing Address - Fax:
Practice Address - Street 1:2525 OAKWOOD AVE NW
Practice Address - Street 2:
Practice Address - City:HUNTSVILLE
Practice Address - State:AL
Practice Address - Zip Code:35810-4410
Practice Address - Country:US
Practice Address - Phone:256-536-1666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-12-19
Last Update Date:2022-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ALT63312183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician