MEDICARE: TANJENIQUE R TRAVIS

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	164W00000X	Licensed Practical Nurse	191727	OH

General Provider Information

NPI Number	:	1104631480
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	TANJENIQUE R TRAVIS

Provider Business Mailing Address
First Line	:	4609 E 173RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-3903
Country	:	US
Telephone Number	:	216-533-4811
Fax Number	:

Provider Business Practice Location Address
First Line	:	4609 E 173RD ST
Second Line	:
City	:	CLEVELAND
State	:	OH
Zip	:	44128-3903
Country	:	US
Telephone Number	:	216-533-4811
Fax Number	:

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

Provider Enumeration Date	:	02/12/2025
Last Update Date	:	02/18/2025

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Directions to “ TANJENIQUE R TRAVIS ” Practice Location

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