Provider Demographics
NPI:1013653971
Name:TRAVIS, ROCHELLE
Entity Type:Individual
Prefix:
First Name:ROCHELLE
Middle Name:
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 1:25 BAY HILL RD
Mailing Address - Street 2:
Mailing Address - City:LAKEWOOD
Mailing Address - State:NJ
Mailing Address - Zip Code:08701-3872
Mailing Address - Country:US
Mailing Address - Phone:848-245-4347
Mailing Address - Fax:
Practice Address - Street 1:25 BAY HILL RD
Practice Address - Street 2:
Practice Address - City:LAKEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:08701-3872
Practice Address - Country:US
Practice Address - Phone:848-245-4347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-12
Last Update Date:2022-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY348776363LF0000X
NJ26NJ332700363LF0000X
NJ26NJ01332700363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily