Provider Demographics
NPI:1417673658
Name:DESTA, ZION KETEMA
Entity Type:Individual
Prefix:
First Name:ZION
Middle Name:KETEMA
Last Name:DESTA
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 1:648 E SANDRA LN
Mailing Address - Street 2:
Mailing Address - City:GRAND PRAIRIE
Mailing Address - State:TX
Mailing Address - Zip Code:75052-2533
Mailing Address - Country:US
Mailing Address - Phone:972-607-5154
Mailing Address - Fax:
Practice Address - Street 1:11330 LEGACY DR STE 103
Practice Address - Street 2:
Practice Address - City:FRISCO
Practice Address - State:TX
Practice Address - Zip Code:75033-1210
Practice Address - Country:US
Practice Address - Phone:469-777-4691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-19
Last Update Date:2022-10-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX2022064183363LP0808X
TX1096608363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health