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General NPI Number Information
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NPI Number | 1184183279
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Entity Type | Individual
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Provider Name | ERICKA TRAVIS
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Gender | Female
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Dates
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Enumeration Date | 03/18/2019
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Last Update Date | 06/11/2019
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Provider Practice Location Address
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Address Line | 106 S MAIN ST
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City | YAZOO CITY
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State | MS
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Zip | 39194-4008
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Country | US
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Telephone | 601-214-2009
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Fax |
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Provider Business Mailing Address
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Address Line | 471 ROOSEVELT ST
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City | CANTON
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State | MS
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Zip | 39046-3535
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Country | US
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Telephone |
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 126800000X
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Taxonomy Name | Dental Assistant
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 251E00000X
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Taxonomy Name | Home Health Agency
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License Number |
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License Number State |
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Taxonomy #3
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Taxonomy Code | 172A00000X
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Taxonomy Name | Driver
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License Number |
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License Number State |
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