Provider Demographics
NPI:1063624039
Name:TRAVIS, KRISTA ROSE (LPN)
Entity type:Individual
Prefix:
First Name:KRISTA
Middle Name:ROSE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1554 MURDOCK RD
Mailing Address - Street 2:
Mailing Address - City:LYNDONVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14098-9731
Mailing Address - Country:US
Mailing Address - Phone:585-765-3955
Mailing Address - Fax:
Practice Address - Street 1:1554 MURDOCK RD
Practice Address - Street 2:
Practice Address - City:LYNDONVILLE
Practice Address - State:NY
Practice Address - Zip Code:14098-9731
Practice Address - Country:US
Practice Address - Phone:585-765-3955
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-04
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY276679-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY02570285Medicaid