Provider Demographics
NPI:1295021079
Name:DESTREE, KATRINA LYNN (MD)
Entity type:Individual
Prefix:DR
First Name:KATRINA
Middle Name:LYNN
Last Name:DESTREE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:DR
Other - First Name:KATRINA
Other - Middle Name:LYNN
Other - Last Name:GUCKENBERG
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:PO BOX 28900
Mailing Address - Street 2:
Mailing Address - City:GREEN BAY
Mailing Address - State:WI
Mailing Address - Zip Code:54324-0900
Mailing Address - Country:US
Mailing Address - Phone:920-490-9046
Mailing Address - Fax:
Practice Address - Street 1:2845 GREENBRIER RD
Practice Address - Street 2:
Practice Address - City:GREEN BAY
Practice Address - State:WI
Practice Address - Zip Code:54311-6519
Practice Address - Country:US
Practice Address - Phone:920-288-4060
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-06-21
Last Update Date:2024-04-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0101252351207P00000X
WI735-00207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine