Basic Information
Provider Information | |||||||||
NPI: | 1255597811 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | TAYLOR | ||||||||
FirstName: | TRAVIS | ||||||||
MiddleName: | LEE | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | FNP-C, CRNFA | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 335 S LAVINA AVE | ||||||||
Address2: |   | ||||||||
City: | SANDPOINT | ||||||||
State: | ID | ||||||||
PostalCode: | 838641721 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2089468219 | ||||||||
FaxNumber: |   | ||||||||
Practice Location | |||||||||
Address1: | 30544 HIGHWAY 200 STE 102 | ||||||||
Address2: |   | ||||||||
City: | PONDERAY | ||||||||
State: | ID | ||||||||
PostalCode: | 838525005 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 2082659817 | ||||||||
FaxNumber: |   | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 08/04/2008 | ||||||||
LastUpdateDate: | 07/05/2014 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | M | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163WR0006X | N-37973 | ID | N |   | Nursing Service Providers | Registered Nurse | Registered Nurse First Assistant | 363LF0000X | NP-1376A | ID | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.