Provider Demographics
NPI:1114543691
Name:DESTRIES, JEANNINE MARIE (FNP)
Entity Type:Individual
Prefix:
First Name:JEANNINE
Middle Name:MARIE
Last Name:DESTRIES
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:248 WHITE CHURCH RD
Mailing Address - Street 2:
Mailing Address - City:BROOKTONDALE
Mailing Address - State:NY
Mailing Address - Zip Code:14817-9766
Mailing Address - Country:US
Mailing Address - Phone:607-279-1621
Mailing Address - Fax:
Practice Address - Street 1:4435 SENECA RD
Practice Address - Street 2:
Practice Address - City:TRUMANSBURG
Practice Address - State:NY
Practice Address - Zip Code:14886-9201
Practice Address - Country:US
Practice Address - Phone:607-387-5707
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-06-22
Last Update Date:2020-06-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF345948-01363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily