Basic Information
| Provider Information | |||||||||
| NPI: | 1518422070 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | ARCHER | ||||||||
| FirstName: | TRISTA | ||||||||
| MiddleName: | J | ||||||||
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| Credential: | QMHS | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2000 NOBLE DR | ||||||||
| Address2: | |||||||||
| City: | WOOSTER | ||||||||
| State: | OH | ||||||||
| PostalCode: | 446915353 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3302643232 | ||||||||
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| Practice Location | |||||||||
| Address1: | 40060 NATIONAL RD | ||||||||
| Address2: | |||||||||
| City: | BETHESDA | ||||||||
| State: | OH | ||||||||
| PostalCode: | 437199763 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7407820092 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 02/08/2019 | ||||||||
| LastUpdateDate: | 09/09/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 171M00000X | N | Other Service Providers | Case Manager/Care Coordinator | 164W00000X | 172249 | OH | Y | Nursing Service Providers | Licensed Practical Nurse |
No ID Information.