Provider Demographics
NPI:1134595226
Name:TRAVIS, KIMBERLY
Entity type:Individual
Prefix:
First Name:KIMBERLY
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 1:3032 SAVANNAH WAY
Mailing Address - Street 2:APT 204
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32935-3640
Mailing Address - Country:US
Mailing Address - Phone:321-704-3981
Mailing Address - Fax:
Practice Address - Street 1:3032 SAVANNAH WAY
Practice Address - Street 2:APT 204
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32935-3640
Practice Address - Country:US
Practice Address - Phone:321-704-3981
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-08-12
Last Update Date:2015-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCNA 297014376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide