Provider Demographics
NPI:1306449103
Name:TRAVIS, SISTIVA MAUREEN
Entity type:Individual
Prefix:
First Name:SISTIVA
Middle Name:MAUREEN
Last Name:TRAVIS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4281 SW TUSCOL ST
Mailing Address - Street 2:
Mailing Address - City:PORT ST LUCIE
Mailing Address - State:FL
Mailing Address - Zip Code:34953-6814
Mailing Address - Country:US
Mailing Address - Phone:772-807-1662
Mailing Address - Fax:
Practice Address - Street 1:10000 SW INNOVATION WAY
Practice Address - Street 2:
Practice Address - City:PORT ST LUCIE
Practice Address - State:FL
Practice Address - Zip Code:34987-2111
Practice Address - Country:US
Practice Address - Phone:772-223-5945
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-11-16
Last Update Date:2020-11-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL260101030760092183700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes183700000XPharmacy Service ProvidersPharmacy Technician