Provider Demographics
NPI:1942781182
Name:MOOTY, DESTINY
Entity Type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:MOOTY
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 1:4950 NORTHCUTT PL
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45414-3840
Mailing Address - Country:US
Mailing Address - Phone:937-496-2020
Mailing Address - Fax:
Practice Address - Street 1:475 EASTDALE DR
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45415-2913
Practice Address - Country:US
Practice Address - Phone:937-626-6868
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-08-26
Last Update Date:2023-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH168599164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse