Provider Demographics
NPI:1700384104
Name:TRAVIS, LATESA DENISE
Entity Type:Individual
Prefix:
First Name:LATESA
Middle Name:DENISE
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 1:26034 HIGHWAY 12
Mailing Address - Street 2:
Mailing Address - City:LEXINGTON
Mailing Address - State:MS
Mailing Address - Zip Code:39095-7264
Mailing Address - Country:US
Mailing Address - Phone:662-834-1708
Mailing Address - Fax:662-834-1708
Practice Address - Street 1:26034 HIGHWAY 12
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:MS
Practice Address - Zip Code:39095-7264
Practice Address - Country:US
Practice Address - Phone:662-834-1701
Practice Address - Fax:662-834-1708
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-31
Last Update Date:2018-01-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker