Provider Demographics
NPI:1679399133
Name:NIETO-HOLLESTELLE, TRAVIS (LAC)
Entity type:Individual
Prefix:
First Name:TRAVIS
Middle Name:
Last Name:NIETO-HOLLESTELLE
Suffix:
Gender:M
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17500 NW CORNELL RD APT 3
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97006-3201
Mailing Address - Country:US
Mailing Address - Phone:541-639-2734
Mailing Address - Fax:
Practice Address - Street 1:17500 NW CORNELL RD APT 3
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97006-3201
Practice Address - Country:US
Practice Address - Phone:541-639-2734
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-12-02
Last Update Date:2024-12-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
ORAC222947171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist