Healthcare Provider Details

I. General information

NPI: 1669287181
Provider Name (Legal Business Name): MARTHA TRAVIOLI FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/11/2025
Last Update Date: 07/02/2026
Certification Date: 07/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3909 MEXICO RD
SAINT PETERS MO
63376-6408
US

IV. Provider business mailing address

3909 MEXICO RD
SAINT PETERS MO
63376-6408
US

V. Phone/Fax

Practice location:
  • Phone: 765-569-3178
  • Fax:
Mailing address:
  • Phone: 765-569-3178
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number28224984A
License Number StateIN
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number2025012712
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: