Provider Demographics
NPI:1518422070
Name:ARCHER, TRISTA J (QMHS)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:J
Last Name:ARCHER
Suffix:
Gender:F
Credentials:QMHS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2000 NOBLE DR
Mailing Address - Street 2:
Mailing Address - City:WOOSTER
Mailing Address - State:OH
Mailing Address - Zip Code:44691-5353
Mailing Address - Country:US
Mailing Address - Phone:330-264-3232
Mailing Address - Fax:
Practice Address - Street 1:40060 NATIONAL RD
Practice Address - Street 2:
Practice Address - City:BETHESDA
Practice Address - State:OH
Practice Address - Zip Code:43719-9763
Practice Address - Country:US
Practice Address - Phone:740-782-0092
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-02-08
Last Update Date:2019-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171M00000X
OH172249164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
No171M00000XOther Service ProvidersCase Manager/Care Coordinator