Provider Demographics
NPI:1164568465
Name:DESTRO, JACQUELINE LEE (CRNP)
Entity Type:Individual
Prefix:MRS
First Name:JACQUELINE
Middle Name:LEE
Last Name:DESTRO
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 WOODSIDE RD
Mailing Address - Street 2:
Mailing Address - City:PITTSBURGH
Mailing Address - State:PA
Mailing Address - Zip Code:15221-3638
Mailing Address - Country:US
Mailing Address - Phone:412-247-1704
Mailing Address - Fax:
Practice Address - Street 1:221 PENN AVE
Practice Address - Street 2:
Practice Address - City:WILKINSBURG
Practice Address - State:PA
Practice Address - Zip Code:15221-2118
Practice Address - Country:US
Practice Address - Phone:412-865-6589
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-01-30
Last Update Date:2013-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAUP001881D363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics