Provider Demographics
NPI:1396108155
Name:MILLSAP, DESTRI WAYNE
Entity type:Individual
Prefix:
First Name:DESTRI
Middle Name:WAYNE
Last Name:MILLSAP
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18934 W KELLEY AVE
Mailing Address - Street 2:
Mailing Address - City:HERSHEY
Mailing Address - State:NE
Mailing Address - Zip Code:69143-4375
Mailing Address - Country:US
Mailing Address - Phone:308-870-1978
Mailing Address - Fax:
Practice Address - Street 1:18934 W KELLEY AVE
Practice Address - Street 2:
Practice Address - City:HERSHEY
Practice Address - State:NE
Practice Address - Zip Code:69143-4375
Practice Address - Country:US
Practice Address - Phone:308-870-1978
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-03-30
Last Update Date:2016-03-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE7082255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer