Provider Demographics
NPI:1386180180
Name:HALL, TRISTAN
Entity type:Individual
Prefix:
First Name:TRISTAN
Middle Name:
Last Name:HALL
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:876 SE 46TH LOOP
Mailing Address - Street 2:
Mailing Address - City:KEYSTONE HEIGHTS
Mailing Address - State:FL
Mailing Address - Zip Code:32656-6264
Mailing Address - Country:US
Mailing Address - Phone:352-538-9135
Mailing Address - Fax:
Practice Address - Street 1:876 SE 46TH LOOP
Practice Address - Street 2:
Practice Address - City:KEYSTONE HEIGHTS
Practice Address - State:FL
Practice Address - Zip Code:32656-6264
Practice Address - Country:US
Practice Address - Phone:352-538-9135
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-01-17
Last Update Date:2017-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLPN5208864164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse