Provider Demographics
NPI:1669833000
Name:VANDEN HEUVEL, TRAVIS EDWARD (LPN)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:EDWARD
Last Name:VANDEN HEUVEL
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:N1762 BUCHANAN RD
Mailing Address - Street 2:
Mailing Address - City:KAUKAUNA
Mailing Address - State:WI
Mailing Address - Zip Code:54130-9207
Mailing Address - Country:US
Mailing Address - Phone:920-574-8066
Mailing Address - Fax:
Practice Address - Street 1:N1762 BUCHANAN RD
Practice Address - Street 2:
Practice Address - City:KAUKAUNA
Practice Address - State:WI
Practice Address - Zip Code:54130-9207
Practice Address - Country:US
Practice Address - Phone:920-574-8066
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-03-13
Last Update Date:2016-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI320113 - 31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse