Provider Demographics
NPI:1023311297
Name:TRAVIS, JOHNETTA (RN)
Entity type:Individual
Prefix:
First Name:JOHNETTA
Middle Name:
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3407 DANVERS AVE
Mailing Address - Street 2:
Mailing Address - City:AUGUSTA
Mailing Address - State:GA
Mailing Address - Zip Code:30906-5172
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:950 LANEY WALKER BLVD
Practice Address - Street 2:
Practice Address - City:AUGUSTA
Practice Address - State:GA
Practice Address - Zip Code:30901-2960
Practice Address - Country:US
Practice Address - Phone:706-721-5900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-12-10
Last Update Date:2010-12-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN14321163WW0101X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WW0101XNursing Service ProvidersRegistered NurseWomen's Health Care, Ambulatory