Provider Demographics
NPI:1033307236
Name:BROWN, TRISTA (MS, PT)
Entity Type:Individual
Prefix:MRS
First Name:TRISTA
Middle Name:
Last Name:BROWN
Suffix:
Gender:F
Credentials:MS, PT
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:
Other - Last Name:BRATLEE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:716 E BELLA VISTA ST
Mailing Address - Street 2:
Mailing Address - City:LAKELAND
Mailing Address - State:FL
Mailing Address - Zip Code:33805
Mailing Address - Country:US
Mailing Address - Phone:863-683-6504
Mailing Address - Fax:863-688-9292
Practice Address - Street 1:716 E BELLA VISTA ST
Practice Address - Street 2:
Practice Address - City:LAKELAND
Practice Address - State:FL
Practice Address - Zip Code:33805
Practice Address - Country:US
Practice Address - Phone:863-683-6504
Practice Address - Fax:863-688-9292
Is Sole Proprietor?:No
Enumeration Date:2007-10-12
Last Update Date:2021-05-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL26098225100000X
FLPT260982251P0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2251P0200XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical TherapistPediatrics
No225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist