Provider Demographics
NPI:1316340623
Name:PRUITT, TRISTIN DELRAE (STNA)
Entity type:Individual
Prefix:
First Name:TRISTIN
Middle Name:DELRAE
Last Name:PRUITT
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:TRISTIN
Other - Middle Name:DELRAE
Other - Last Name:TUCKER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:110 RANDALL DR
Mailing Address - Street 2:
Mailing Address - City:SANDUSKY
Mailing Address - State:OH
Mailing Address - Zip Code:44870-5774
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:110 RANDALL DR
Practice Address - Street 2:
Practice Address - City:SANDUSKY
Practice Address - State:OH
Practice Address - Zip Code:44870-5774
Practice Address - Country:US
Practice Address - Phone:419-504-9624
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-09-30
Last Update Date:2014-09-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH400776580708376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide