Provider Demographics
NPI:1790311223
Name:REID, DESTINA SHANTE (PA-C)
Entity Type:Individual
Prefix:
First Name:DESTINA
Middle Name:SHANTE
Last Name:REID
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:
Other - First Name:DESTINA
Other - Middle Name:SHANTE
Other - Last Name:CAMPBELL
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:108 EDGEWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LAGRANGE
Mailing Address - State:GA
Mailing Address - Zip Code:30241-6116
Mailing Address - Country:US
Mailing Address - Phone:706-415-0370
Mailing Address - Fax:
Practice Address - Street 1:108 EDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:LAGRANGE
Practice Address - State:GA
Practice Address - Zip Code:30241-6116
Practice Address - Country:US
Practice Address - Phone:706-415-0370
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-03-16
Last Update Date:2020-03-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA9661363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant