Provider Demographics
NPI:1467283762
Name:KEITH, TRISTA (RN)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:KEITH
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:RN
Mailing Address - Street 1:3480 SHAMROCK LOOP
Mailing Address - Street 2:
Mailing Address - City:DICKINSON
Mailing Address - State:ND
Mailing Address - Zip Code:58601-8383
Mailing Address - Country:US
Mailing Address - Phone:406-480-0174
Mailing Address - Fax:
Practice Address - Street 1:3480 SHAMROCK LOOP
Practice Address - Street 2:
Practice Address - City:DICKINSON
Practice Address - State:ND
Practice Address - Zip Code:58601-8383
Practice Address - Country:US
Practice Address - Phone:406-480-0174
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-09
Last Update Date:2024-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR354913747P1801X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant