Provider Demographics
NPI:1780219410
Name:DESTEFANO, COURTNEY
Entity Type:Individual
Prefix:
First Name:COURTNEY
Middle Name:
Last Name:DESTEFANO
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 1:834 CHESTNUT ST PH 201
Mailing Address - Street 2:
Mailing Address - City:PHILADELPHIA
Mailing Address - State:PA
Mailing Address - Zip Code:19107-5147
Mailing Address - Country:US
Mailing Address - Phone:267-275-7296
Mailing Address - Fax:
Practice Address - Street 1:994 W SHERMAN AVE BLDG 2
Practice Address - Street 2:
Practice Address - City:VINELAND
Practice Address - State:NJ
Practice Address - Zip Code:08360-6937
Practice Address - Country:US
Practice Address - Phone:631-534-7246
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-03
Last Update Date:2022-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ01015900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily