Provider Demographics
NPI:1609593748
Name:CARTER, DESTINY SHANELE (OWNER)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:SHANELE
Last Name:CARTER
Suffix:
Gender:F
Credentials:OWNER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 ZION RD
Mailing Address - Street 2:
Mailing Address - City:GRETNA
Mailing Address - State:VA
Mailing Address - Zip Code:24557-4632
Mailing Address - Country:US
Mailing Address - Phone:434-630-8629
Mailing Address - Fax:
Practice Address - Street 1:140 ZION RD
Practice Address - Street 2:
Practice Address - City:GRETNA
Practice Address - State:VA
Practice Address - Zip Code:24557-4632
Practice Address - Country:US
Practice Address - Phone:434-630-8629
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
VA253150374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide