Provider Demographics
NPI:1215417951
Name:DESTEFANO, DOREEN
Entity Type:Individual
Prefix:
First Name:DOREEN
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12734 KENWOOD LN STE 84
Mailing Address - Street 2:
Mailing Address - City:FORT MYERS
Mailing Address - State:FL
Mailing Address - Zip Code:33907-5638
Mailing Address - Country:US
Mailing Address - Phone:239-425-2900
Mailing Address - Fax:239-791-1072
Practice Address - Street 1:12734 KENWOOD LN STE 84
Practice Address - Street 2:
Practice Address - City:FORT MYERS
Practice Address - State:FL
Practice Address - Zip Code:33907-5638
Practice Address - Country:US
Practice Address - Phone:239-425-2900
Practice Address - Fax:239-791-1072
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-21
Last Update Date:2019-03-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLAPRN1100138363LA2200X
FL9435213163WI0500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163WI0500XNursing Service ProvidersRegistered NurseInfusion Therapy