Provider Demographics
NPI:1003291188
Name:SOS, TRISTA NICOLE (LVN)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:NICOLE
Last Name:SOS
Suffix:
Gender:F
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1907 TIBURON DR
Mailing Address - Street 2:
Mailing Address - City:REDDING
Mailing Address - State:CA
Mailing Address - Zip Code:96003
Mailing Address - Country:US
Mailing Address - Phone:707-362-1751
Mailing Address - Fax:
Practice Address - Street 1:1907 TIBURON DR
Practice Address - Street 2:
Practice Address - City:REDDING
Practice Address - State:CA
Practice Address - Zip Code:96003-9232
Practice Address - Country:US
Practice Address - Phone:707-362-1751
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-07-30
Last Update Date:2015-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN 247964164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse