Provider Demographics
NPI:1346994845
Name:BRISTOL, TINA PATRICE
Entity Type:Individual
Prefix:MRS
First Name:TINA
Middle Name:PATRICE
Last Name:BRISTOL
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 1:4455 ISH BRANT RD W
Mailing Address - Street 2:
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32210-7046
Mailing Address - Country:US
Mailing Address - Phone:904-377-6612
Mailing Address - Fax:
Practice Address - Street 1:4455 ISH BRANT RD W
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32210-7046
Practice Address - Country:US
Practice Address - Phone:904-377-6612
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-04
Last Update Date:2022-02-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL016780800320900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes320900000XResidential Treatment FacilitiesCommunity Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLB62381764947-0Medicaid
FL016780800Medicaid