Provider Demographics
NPI:1699088856
Name:VIRGIL-TRAVIS, BRIDGETTE N (LPN)
Entity type:Individual
Prefix:
First Name:BRIDGETTE
Middle Name:N
Last Name:VIRGIL-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 1:5043 N 19TH ST
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53209-5762
Mailing Address - Country:US
Mailing Address - Phone:414-793-7802
Mailing Address - Fax:
Practice Address - Street 1:5043 N 19TH ST
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53209-3802
Practice Address - Country:US
Practice Address - Phone:414-793-7802
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-16
Last Update Date:2010-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306935-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse