Provider Demographics
NPI:1659721215
Name:DESTA, WAYNI
Entity Type:Individual
Prefix:
First Name:WAYNI
Middle Name:
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:PO BOX 1578
Mailing Address - Street 2:
Mailing Address - City:HELOTES
Mailing Address - State:TX
Mailing Address - Zip Code:78023-1578
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12906 GREEN CEDAR
Practice Address - Street 2:
Practice Address - City:HELOTES
Practice Address - State:TX
Practice Address - Zip Code:78023-4173
Practice Address - Country:US
Practice Address - Phone:830-357-0908
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-06-15
Last Update Date:2016-06-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator