Healthcare Provider Details

I. General information

NPI: 1255597811
Provider Name (Legal Business Name): TRAVIS LEE TAYLOR FNP-C, CRNFA
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/04/2008
Last Update Date: 07/05/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30544 HIGHWAY 200 STE 102
PONDERAY ID
83852-5005
US

IV. Provider business mailing address

335 S LAVINA AVE
SANDPOINT ID
83864-1721
US

V. Phone/Fax

Practice location:
  • Phone: 208-265-9817
  • Fax:
Mailing address:
  • Phone: 208-946-8219
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WR0006X
TaxonomyRegistered Nurse First Assistant
License NumberN-37973
License Number StateID
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP-1376A
License Number StateID

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: