Provider Demographics
NPI:1669071775
Name:DESTINY MEDICAL PRACTICE LLC
Entity type:Organization
Organization Name:DESTINY MEDICAL PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:
Authorized Official - First Name:VIDA-LYNN
Authorized Official - Middle Name:
Authorized Official - Last Name:ASIAMAH- ASARE
Authorized Official - Suffix:
Authorized Official - Credentials:APN
Authorized Official - Phone:917-204-3333
Mailing Address - Street 1:PO BOX 544
Mailing Address - Street 2:
Mailing Address - City:RANCOCAS
Mailing Address - State:NJ
Mailing Address - Zip Code:08073-0544
Mailing Address - Country:US
Mailing Address - Phone:609-496-3494
Mailing Address - Fax:
Practice Address - Street 1:10 AMARA LN
Practice Address - Street 2:
Practice Address - City:WESTAMPTON
Practice Address - State:NJ
Practice Address - Zip Code:08060-5753
Practice Address - Country:US
Practice Address - Phone:914-204-3348
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-10-20
Last Update Date:2020-11-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty