Provider Demographics
NPI:1922637313
Name:TRIST, MARY MICAH CRESSY (DNP, CRNA)
Entity Type:Individual
Prefix:MRS
First Name:MARY MICAH
Middle Name:CRESSY
Last Name:TRIST
Suffix:
Gender:F
Credentials:DNP, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:511 LAKEWOOD NORTHSHORE DR
Mailing Address - Street 2:
Mailing Address - City:COVINGTON
Mailing Address - State:LA
Mailing Address - Zip Code:70433-1935
Mailing Address - Country:US
Mailing Address - Phone:985-778-6713
Mailing Address - Fax:
Practice Address - Street 1:511 LAKEWOOD NORTHSHORE DR
Practice Address - Street 2:
Practice Address - City:COVINGTON
Practice Address - State:LA
Practice Address - Zip Code:70433-1935
Practice Address - Country:US
Practice Address - Phone:985-778-6713
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-04-07
Last Update Date:2022-01-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
LA220570367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program