Healthcare Provider Details

I. General information

NPI: 1194002089
Provider Name (Legal Business Name): TRISTEN ANTOINISE LAMAR
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: TRISTEN LAMAR

II. Dates (important events)

Enumeration Date: 11/07/2011
Last Update Date: 03/07/2023
Certification Date: 03/07/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4411 E KINGS CANYON RD
FRESNO CA
93702-3604
US

IV. Provider business mailing address

4411 E KINGS CANYON RD
FRESNO CA
93702-3604
US

V. Phone/Fax

Practice location:
  • Phone: 559-453-5199
  • Fax:
Mailing address:
  • Phone: 559-453-5199
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code164X00000X
TaxonomyLicensed Vocational Nurse
License Number252974
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: