Provider Demographics
NPI:1942053384
Name:PHILLIPS, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:PHILLIPS
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 1:226 JEFFERY LN
Mailing Address - Street 2:
Mailing Address - City:PENSACOLA
Mailing Address - State:FL
Mailing Address - Zip Code:32514-3821
Mailing Address - Country:US
Mailing Address - Phone:850-346-2669
Mailing Address - Fax:
Practice Address - Street 1:226 JEFFERY LN
Practice Address - Street 2:
Practice Address - City:PENSACOLA
Practice Address - State:FL
Practice Address - Zip Code:32514-3821
Practice Address - Country:US
Practice Address - Phone:850-346-2669
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-04-08
Last Update Date:2024-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLMA93446225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist