Provider Demographics
NPI:1548749468
Name:BLADEGROEN, TRISTA (LVN)
Entity Type:Individual
Prefix:
First Name:TRISTA
Middle Name:
Last Name:BLADEGROEN
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:
Other - Last Name:OVIEDO
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:LVN
Mailing Address - Street 1:10609 W IH 10 STE 105
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78230-1673
Mailing Address - Country:US
Mailing Address - Phone:210-344-5437
Mailing Address - Fax:210-340-1259
Practice Address - Street 1:10609 W IH 10 STE 105
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78230-1673
Practice Address - Country:US
Practice Address - Phone:210-344-5437
Practice Address - Fax:210-340-1259
Is Sole Proprietor?:No
Enumeration Date:2018-08-10
Last Update Date:2018-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX225513164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX173913801Medicaid