Provider Demographics
NPI:1447717210
Name:VANASSE, TRISTA MICHELE (CRNA)
Entity type:Individual
Prefix:
First Name:TRISTA
Middle Name:MICHELE
Last Name:VANASSE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:TRISTA
Other - Middle Name:MICHELE
Other - Last Name:KALLENBACK
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1027 WOOD HOLLOW CIR
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:94533-1667
Mailing Address - Country:US
Mailing Address - Phone:707-631-9315
Mailing Address - Fax:
Practice Address - Street 1:1 QUALITY DR
Practice Address - Street 2:
Practice Address - City:VACAVILLE
Practice Address - State:CA
Practice Address - Zip Code:95688-9494
Practice Address - Country:US
Practice Address - Phone:707-624-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-02-27
Last Update Date:2019-02-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001091367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered