Provider Demographics
NPI:1639627755
Name:DESTRAT, GUILAINE
Entity Type:Individual
Prefix:
First Name:GUILAINE
Middle Name:
Last Name:DESTRAT
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 1:3350 W HILLSBOROUGH AVE
Mailing Address - Street 2:APT 1218
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33614-1309
Mailing Address - Country:US
Mailing Address - Phone:301-266-7290
Mailing Address - Fax:
Practice Address - Street 1:1313 E FLETCHER AVE
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33612-3629
Practice Address - Country:US
Practice Address - Phone:301-266-7290
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-09-19
Last Update Date:2016-09-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCL12427441744P3200X
MD4287981744P3200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes1744P3200XOther Service ProvidersSpecialistProsthetics Case Management