Provider Demographics
NPI:1952854705
Name:NEELY, TRAVIS L
Entity Type:Individual
Prefix:
First Name:TRAVIS
Middle Name:L
Last Name:NEELY
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:433 N ARIZONA AVE
Mailing Address - Street 2:
Mailing Address - City:PRESCOTT
Mailing Address - State:AZ
Mailing Address - Zip Code:86301-2605
Mailing Address - Country:US
Mailing Address - Phone:928-420-5379
Mailing Address - Fax:
Practice Address - Street 1:433 N ARIZONA AVE
Practice Address - Street 2:
Practice Address - City:PRESCOTT
Practice Address - State:AZ
Practice Address - Zip Code:86301-2605
Practice Address - Country:US
Practice Address - Phone:928-420-5379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-07-28
Last Update Date:2016-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide