Provider Demographics
NPI:1346993763
Name:GROSSNICKLE, TRISTA LOUISE (PMHNP)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:LOUISE
Last Name:GROSSNICKLE
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:400 W GLENN MILLER DR
Mailing Address - Street 2:
Mailing Address - City:CLARINDA
Mailing Address - State:IA
Mailing Address - Zip Code:51632-2963
Mailing Address - Country:US
Mailing Address - Phone:712-542-8354
Mailing Address - Fax:712-517-1192
Practice Address - Street 1:400 W GLENN MILLER DR
Practice Address - Street 2:
Practice Address - City:CLARINDA
Practice Address - State:IA
Practice Address - Zip Code:51632-2963
Practice Address - Country:US
Practice Address - Phone:712-542-8354
Practice Address - Fax:712-517-1192
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-27
Last Update Date:2022-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAG167240363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty