Provider Demographics
NPI:1124099924
Name:BRISTOW, LEE ANN (APRN-CNM, MS)
Entity type:Individual
Prefix:
First Name:LEE
Middle Name:ANN
Last Name:BRISTOW
Suffix:
Gender:F
Credentials:APRN-CNM, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12991 EMERSON RD
Mailing Address - Street 2:
Mailing Address - City:APPLE CREEK
Mailing Address - State:OH
Mailing Address - Zip Code:44606-9302
Mailing Address - Country:US
Mailing Address - Phone:330-857-0177
Mailing Address - Fax:330-857-0190
Practice Address - Street 1:12991 EMERSON RD
Practice Address - Street 2:
Practice Address - City:APPLE CREEK
Practice Address - State:OH
Practice Address - Zip Code:44606-9302
Practice Address - Country:US
Practice Address - Phone:330-857-0177
Practice Address - Fax:330-857-0190
Is Sole Proprietor?:No
Enumeration Date:2006-01-30
Last Update Date:2021-07-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH268563367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA2137968Medicaid