Provider Demographics
NPI:1194874990
Name:TRAVIS, GEORGANNA LOUISE (LPN)
Entity type:Individual
Prefix:
First Name:GEORGANNA
Middle Name:LOUISE
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:397 E 222ND ST
Mailing Address - Street 2:B15
Mailing Address - City:EUCLID
Mailing Address - State:OH
Mailing Address - Zip Code:44123-1747
Mailing Address - Country:US
Mailing Address - Phone:216-299-9977
Mailing Address - Fax:
Practice Address - Street 1:397 E 222ND ST
Practice Address - Street 2:B15
Practice Address - City:EUCLID
Practice Address - State:OH
Practice Address - Zip Code:44123-1747
Practice Address - Country:US
Practice Address - Phone:216-299-9977
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-01-09
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH121595164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2639989Medicaid