MEDICARE: MRS. LUCILLE TRAVIS NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LG0600X	Gerontology Nurse Practitioner	RN195568	GA
2	363LP2300X	Primary Care Nurse Practitioner	RN195568	GA

General Provider Information

NPI Number	:	1093206674
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LUCILLE TRAVIS NP

Provider Business Mailing Address
First Line	:	4095 ATLANTA HWY
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-1854
Country	:	US
Telephone Number	:	404-488-9521
Fax Number	:	404-836-8030

Provider Business Practice Location Address
First Line	:	4095 ATLANTA HWY
Second Line	:
City	:	HIRAM
State	:	GA
Zip	:	30141-1854
Country	:	US
Telephone Number	:	404-488-9521
Fax Number	:	404-836-8030

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	05/19/2018
Last Update Date	:	01/17/2024

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