Provider Demographics
NPI:1134777865
Name:ROSE, TRISTA RENEE
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:RENEE
Last Name:ROSE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10421 RIVERDALE RISE DR
Mailing Address - Street 2:
Mailing Address - City:RIVERVIEW
Mailing Address - State:FL
Mailing Address - Zip Code:33578-4065
Mailing Address - Country:US
Mailing Address - Phone:269-274-7251
Mailing Address - Fax:
Practice Address - Street 1:10421 RIVERDALE RISE DR
Practice Address - Street 2:
Practice Address - City:RIVERVIEW
Practice Address - State:FL
Practice Address - Zip Code:33578-4065
Practice Address - Country:US
Practice Address - Phone:269-274-7251
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-27
Last Update Date:2019-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider