Tina Patrice Bristol

Primary specialty

Intellectual and/or Developmental Disabilities Community Based Residential Treatment FacilityTaxonomy code 320900000X

License

016780800 Issued in FL

Practice address

4455 Ish Brant Rd W
Jacksonville, FL 32210-7046

Phone

(904) 377-6612

NPI assigned

Feb 4, 2022

Sex

Female

Sole proprietor

Yes

Registry information is reported by the provider to CMS and is not verified. About this source

Specialties & licenses 1

Addresses

Other identifiers 2

Medicare fee-for-service enrollment

Not listed in the public Medicare enrollment file

Medicare enrollment (NPD)

Not enrolled

State licenses

The complete NPPES record for this NPI in the NPI Registry API format.

{
    "created_epoch": "1643932800000",
    "enumeration_type": "NPI-1",
    "last_updated_epoch": "1643932800000",
    "number": "1346994845",
    "addresses": [
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "MAILING",
            "address_type": "DOM",
            "address_1": "4455 ISH BRANT RD W",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322107046",
            "telephone_number": "904-377-6612"
        },
        {
            "country_code": "US",
            "country_name": "United States",
            "address_purpose": "LOCATION",
            "address_type": "DOM",
            "address_1": "4455 ISH BRANT RD W",
            "city": "JACKSONVILLE",
            "state": "FL",
            "postal_code": "322107046",
            "telephone_number": "904-377-6612"
        }
    ],
    "practiceLocations": [],
    "basic": {
        "last_name": "BRISTOL",
        "first_name": "TINA",
        "middle_name": "PATRICE",
        "name_prefix": "Mrs.",
        "sole_proprietor": "YES",
        "sex": "F",
        "enumeration_date": "2022-02-04",
        "last_updated": "2022-02-04",
        "certification_date": "2022-02-04",
        "status": "A"
    },
    "taxonomies": [
        {
            "code": "320900000X",
            "taxonomy_group": "",
            "desc": "Community Based Residential Treatment Facility, Intellectual and/or Developmental Disabilities",
            "state": "FL",
            "license": "016780800",
            "primary": true
        }
    ],
    "identifiers": [
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "B62381764947-0",
            "state": "FL"
        },
        {
            "code": "05",
            "desc": "MEDICAID",
            "issuer": null,
            "identifier": "016780800",
            "state": "FL"
        }
    ],
    "endpoints": [],
    "other_names": []
}

• Ashley Brisbane
• Brad A Briscoe, APRN, ACNP-BC, CNS
• Reginald F Briscoe III, PHARMD
• Vanessa Jones Briscoe, APRN, BC
• Floyd Llester Bristol
• Michael Eric Bristow, ARNP
• Sabrina Brite
• Alina Brito
• Javier Jude Brito, DDS
• Taylor Brittan, MD

• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Jacksonville, FL
• Providers in Jacksonville, FL by specialty
• Intellectual and/or Developmental Disabilities Community Based Residential Treatment Facility in Florida

• NPPES NPI Registry (CMS): identity, addresses, specialties, licenses, identifiers and endpoints. Last updated by the provider on Feb 4, 2022; self-reported and not verified by CMS. Specialty names from the NUCC taxonomy.
• National Provider Directory (CMS): practice roles, locations, licenses, networks and endpoints.

Verify at the official NPI Registry.