Provider Demographics
NPI:1306632443
Name:JOHNSON, TRISTA
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:JOHNSON
Suffix:
Gender:X
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2799 STATE HIGHWAY 155
Mailing Address - Street 2:
Mailing Address - City:LONE STAR
Mailing Address - State:TX
Mailing Address - Zip Code:75668-5231
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2799 STATE HIGHWAY 155
Practice Address - Street 2:
Practice Address - City:LONE STAR
Practice Address - State:TX
Practice Address - Zip Code:75668-5231
Practice Address - Country:US
Practice Address - Phone:903-755-4180
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-16
Last Update Date:2025-04-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXL-311970163WL0100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WL0100XNursing Service ProvidersRegistered NurseLactation Consultant