Provider Demographics
NPI:1134783384
Name:DESTINA, ROSE-LAURE (NP)
Entity type:Individual
Prefix:MS
First Name:ROSE-LAURE
Middle Name:
Last Name:DESTINA
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:140 LUCILLE AVE
Mailing Address - Street 2:
Mailing Address - City:ELMONT
Mailing Address - State:NY
Mailing Address - Zip Code:11003-2722
Mailing Address - Country:US
Mailing Address - Phone:917-348-1747
Mailing Address - Fax:
Practice Address - Street 1:1111 AMSTERDAM AVE APT 8B
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10025-1716
Practice Address - Country:US
Practice Address - Phone:212-523-2422
Practice Address - Fax:212-523-2402
Is Sole Proprietor?:Yes
Enumeration Date:2019-04-23
Last Update Date:2019-04-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY344119363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily