Provider Demographics
NPI:1942587670
Name:TRAVIS, AMANDA JILL
Entity Type:Individual
Prefix:MRS
First Name:AMANDA
Middle Name:JILL
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2646 FALL SPRING DR
Mailing Address - Street 2:
Mailing Address - City:OLIVE BRANCH
Mailing Address - State:MS
Mailing Address - Zip Code:38654-9476
Mailing Address - Country:US
Mailing Address - Phone:901-359-5409
Mailing Address - Fax:
Practice Address - Street 1:1920 KIRBY PKWY
Practice Address - Street 2:SUITE 100
Practice Address - City:GERMANTOWN
Practice Address - State:TN
Practice Address - Zip Code:38138-3696
Practice Address - Country:US
Practice Address - Phone:901-751-0050
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-11-09
Last Update Date:2013-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN16198363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily