Provider Demographics
NPI:1679991905
Name:HENN, TRISTAN ELIZABETH (DO)
Entity Type:Individual
Prefix:DR
First Name:TRISTAN
Middle Name:ELIZABETH
Last Name:HENN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:TRISTAN
Other - Middle Name:ELIZABETH
Other - Last Name:WADE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:DO
Mailing Address - Street 1:5778 DARROW RD STE 201
Mailing Address - Street 2:
Mailing Address - City:HUDSON
Mailing Address - State:OH
Mailing Address - Zip Code:44236-3808
Mailing Address - Country:US
Mailing Address - Phone:330-655-2161
Mailing Address - Fax:330-650-2116
Practice Address - Street 1:5778 DARROW RD STE 201
Practice Address - Street 2:
Practice Address - City:HUDSON
Practice Address - State:OH
Practice Address - Zip Code:44236-3808
Practice Address - Country:US
Practice Address - Phone:330-655-2161
Practice Address - Fax:330-650-2116
Is Sole Proprietor?:No
Enumeration Date:2014-04-03
Last Update Date:2021-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH390200000X
OH34.012803207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program