Provider Demographics
NPI:1821505769
Name:BRISTER, TONYA (FNP-C)
Entity Type:Individual
Prefix:
First Name:TONYA
Middle Name:
Last Name:BRISTER
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:139 THORNHILL RD
Mailing Address - Street 2:
Mailing Address - City:JAYESS
Mailing Address - State:MS
Mailing Address - Zip Code:39641-8028
Mailing Address - Country:US
Mailing Address - Phone:601-303-6144
Mailing Address - Fax:
Practice Address - Street 1:521 MARION AVE
Practice Address - Street 2:
Practice Address - City:MCCOMB
Practice Address - State:MS
Practice Address - Zip Code:39648-2009
Practice Address - Country:US
Practice Address - Phone:601-600-2053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-31
Last Update Date:2018-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS902478363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily