Healthcare Provider Details

I. General information

NPI: 1942587670
Provider Name (Legal Business Name): MRS. AMANDA JILL TRAVIS
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/09/2011
Last Update Date: 11/20/2025
Certification Date: 11/20/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1920 KIRBY PKWY SUITE 100
GERMANTOWN TN
38138-3696
US

IV. Provider business mailing address

2646 FALL SPRING DR
OLIVE BRANCH MS
38654-9476
US

V. Phone/Fax

Practice location:
  • Phone: 901-751-0050
  • Fax:
Mailing address:
  • Phone: 901-359-5409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number16198
License Number StateTN
# 2
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number16198
License Number StateTN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: