Provider Demographics
NPI:1518691773
Name:WHITMORE, TRYSTON
Entity Type:Individual
Prefix:
First Name:TRYSTON
Middle Name:
Last Name:WHITMORE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5374 RIDDLE RD
Mailing Address - Street 2:
Mailing Address - City:RAVENNA
Mailing Address - State:OH
Mailing Address - Zip Code:44266-9202
Mailing Address - Country:US
Mailing Address - Phone:330-212-8509
Mailing Address - Fax:
Practice Address - Street 1:5374 RIDDLE RD
Practice Address - Street 2:
Practice Address - City:RAVENNA
Practice Address - State:OH
Practice Address - Zip Code:44266-9202
Practice Address - Country:US
Practice Address - Phone:330-212-8509
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-07-13
Last Update Date:2022-07-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide