1578894242 NPI number — MRS. MARY KRISTINE TRAVIS MS RD

Table of content: MRS. MARY KRISTINE TRAVIS MS RD (NPI 1578894242)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1578894242 NPI number — MRS. MARY KRISTINE TRAVIS MS RD

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
TRAVIS
Provider First Name:
MARY
Provider Middle Name:
KRISTINE
Provider Name Prefix Text:
MRS.
Provider Name Suffix Text:
Provider Credential Text:
MS RD
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
SHOENBERGER
Provider Other First Name:
KRISTINE
Provider Other Middle Name:
TRAVIS
Provider Other Name Prefix Text:
MRS.
Provider Other Name Suffix Text:
Provider Other Credential Text:
MS RD
Provider Other Last Name Type Code:
1

NPI Number Information

NPI Number:
1578894242
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
07/24/2026
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
896 SAGEWOOD DR.
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
SOUTH LAKE TAHOE
Provider Business Mailing Address State Name:
CA
Provider Business Mailing Address Postal Code:
96150
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
352-570-6279
Provider Business Mailing Address Fax Number:
775-829-7970

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
896 SAGEWOOD DR.
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
SOUTH LAKE TAHOE
Provider Business Practice Location Address State Name:
CA
Provider Business Practice Location Address Postal Code:
96150
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
352-570-6279
Provider Business Practice Location Address Fax Number:
775-336-3345
Provider Enumeration Date:
01/20/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 133V00000X , with the licence number:  966198 , registered in the state of NV ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)





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