Provider Demographics
NPI:1104901289
Name:TRAVLOS, DIANE M (APN)
Entity type:Individual
Prefix:MS
First Name:DIANE
Middle Name:M
Last Name:TRAVLOS
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 191
Mailing Address - Street 2:
Mailing Address - City:ROCKLAND
Mailing Address - State:DE
Mailing Address - Zip Code:19732-0191
Mailing Address - Country:US
Mailing Address - Phone:302-651-4000
Mailing Address - Fax:302-651-5458
Practice Address - Street 1:THOMAS JEFFERSON UNIVERSITY HOSPITAL
Practice Address - Street 2:111 S. 11TH STREET
Practice Address - City:PHILADELPHIA
Practice Address - State:PA
Practice Address - Zip Code:19107
Practice Address - Country:US
Practice Address - Phone:215-955-6000
Practice Address - Fax:215-923-9519
Is Sole Proprietor?:No
Enumeration Date:2006-10-26
Last Update Date:2018-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DELM-0000160363L00000X
PAVP003505J363LN0000X, 363LN0005X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
No363LN0005XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal, Critical Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
NJ0021679Medicaid
MD4039068Medicaid
NJ0021679Medicaid
MD4039068Medicaid