Healthcare Provider Details

I. General information

NPI: 1588965610
Provider Name (Legal Business Name): TRISTA TETRO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/05/2010
Last Update Date: 11/05/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

557 POLK 72
MENA AR
71953-7720
US

IV. Provider business mailing address

PO BOX 485
MENA AR
71953-0485
US

V. Phone/Fax

Practice location:
  • Phone: 479-243-0490
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374J00000X
TaxonomyDoula
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: