Provider Demographics
NPI:1598454563
Name:DESTA, MERON
Entity Type:Individual
Prefix:MRS
First Name:MERON
Middle Name:
Last Name:DESTA
Suffix:
Gender:F
Credentials:
Other - Prefix:MRS
Other - First Name:MERON
Other - Middle Name:DESTA
Other - Last Name:GESSESE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9900 GOTHIC AVE
Mailing Address - Street 2:
Mailing Address - City:NORTH HILLS
Mailing Address - State:CA
Mailing Address - Zip Code:91343-1246
Mailing Address - Country:US
Mailing Address - Phone:818-304-2907
Mailing Address - Fax:
Practice Address - Street 1:25880 MCBEAN PKWY
Practice Address - Street 2:
Practice Address - City:SANTA CLARITA
Practice Address - State:CA
Practice Address - Zip Code:91355-2004
Practice Address - Country:US
Practice Address - Phone:661-254-3766
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-05-04
Last Update Date:2023-05-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023853363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily