Provider Demographics
NPI:1790284503
Name:PRYATEL, DESTINY KAY (LSW)
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:KAY
Last Name:PRYATEL
Suffix:
Gender:F
Credentials:LSW
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2445 PARK AVE
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55404-3714
Mailing Address - Country:US
Mailing Address - Phone:612-343-3265
Mailing Address - Fax:612-343-3267
Practice Address - Street 1:2445 PARK AVE
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55404-3714
Practice Address - Country:US
Practice Address - Phone:612-343-3265
Practice Address - Fax:612-343-3267
Is Sole Proprietor?:No
Enumeration Date:2018-02-07
Last Update Date:2018-02-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN26919171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN26919OtherLSW