Provider Demographics
NPI:1811164122
Name:CLEMMER, TRISTA DELORIS (LPN)
Entity type:Individual
Prefix:MISS
First Name:TRISTA
Middle Name:DELORIS
Last Name:CLEMMER
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:618 S CHURCH ST
Mailing Address - Street 2:
Mailing Address - City:GRANTSBURG
Mailing Address - State:WI
Mailing Address - Zip Code:54840-7866
Mailing Address - Country:US
Mailing Address - Phone:715-220-1995
Mailing Address - Fax:
Practice Address - Street 1:618 S CHURCH ST
Practice Address - Street 2:
Practice Address - City:GRANTSBURG
Practice Address - State:WI
Practice Address - Zip Code:54840-7866
Practice Address - Country:US
Practice Address - Phone:715-220-1995
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-05-15
Last Update Date:2008-05-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI306540-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI3950845470Medicaid