Provider Demographics
NPI:1912500141
Name:BRISTEL, DWIGHT ANTHONY
Entity Type:Individual
Prefix:
First Name:DWIGHT
Middle Name:ANTHONY
Last Name:BRISTEL
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6929 ELLEN BOAT LN
Mailing Address - Street 2:
Mailing Address - City:CANAL WINCHESTER
Mailing Address - State:OH
Mailing Address - Zip Code:43110-7913
Mailing Address - Country:US
Mailing Address - Phone:614-778-6098
Mailing Address - Fax:
Practice Address - Street 1:6929 ELLEN BOAT LN
Practice Address - Street 2:
Practice Address - City:CANAL WINCHESTER
Practice Address - State:OH
Practice Address - Zip Code:43110-7913
Practice Address - Country:US
Practice Address - Phone:614-778-6098
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-19
Last Update Date:2020-11-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH2756544374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide