Provider Demographics
NPI:1760198683
Name:WANDEN, DESTANY L
Entity Type:Individual
Prefix:
First Name:DESTANY
Middle Name:L
Last Name:WANDEN
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 1:4884 21ST AVE S APT 301
Mailing Address - Street 2:
Mailing Address - City:FARGO
Mailing Address - State:ND
Mailing Address - Zip Code:58103-7753
Mailing Address - Country:US
Mailing Address - Phone:701-580-8196
Mailing Address - Fax:
Practice Address - Street 1:403 9TH ST S
Practice Address - Street 2:
Practice Address - City:FARGO
Practice Address - State:ND
Practice Address - Zip Code:58103-1837
Practice Address - Country:US
Practice Address - Phone:701-580-8196
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-24
Last Update Date:2023-01-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant