Provider Demographics
NPI:1376871418
Name:DESTIN, NANCY P (PT)
Entity Type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:P
Last Name:DESTIN
Suffix:
Gender:F
Credentials:PT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10031 PINES BLVD
Mailing Address - Street 2:STE 217
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33024-6169
Mailing Address - Country:US
Mailing Address - Phone:954-305-5001
Mailing Address - Fax:954-391-9736
Practice Address - Street 1:10031 PINES BLVD
Practice Address - Street 2:STE 217
Practice Address - City:PEMBROKE PINES
Practice Address - State:FL
Practice Address - Zip Code:33024-6169
Practice Address - Country:US
Practice Address - Phone:954-305-5001
Practice Address - Fax:954-367-3739
Is Sole Proprietor?:Yes
Enumeration Date:2009-12-01
Last Update Date:2020-02-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL20418225100000X
FLPT20418222Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
No222Q00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersDevelopmental Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL889068400Medicaid