Provider Demographics
NPI:1376252080
Name:LANDERS, DESTINY J
Entity Type:Individual
Prefix:MISS
First Name:DESTINY
Middle Name:J
Last Name:LANDERS
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DESTINED
Other - Middle Name:4
Other - Last Name:GREATNESS
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:919 MODESTO DR
Mailing Address - Street 2:
Mailing Address - City:ROSHARON
Mailing Address - State:TX
Mailing Address - Zip Code:77583-3754
Mailing Address - Country:US
Mailing Address - Phone:346-391-7291
Mailing Address - Fax:
Practice Address - Street 1:919 MODESTO DR
Practice Address - Street 2:
Practice Address - City:ROSHARON
Practice Address - State:TX
Practice Address - Zip Code:77583-3754
Practice Address - Country:US
Practice Address - Phone:346-391-7291
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-21
Last Update Date:2022-11-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171W00000XOther Service ProvidersContractor