Provider Demographics
NPI:1750089140
Name:VEGA, DESTINY NICHOLE
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:NICHOLE
Last Name:VEGA
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:PO BOX 1658
Mailing Address - Street 2:
Mailing Address - City:AVALON
Mailing Address - State:CA
Mailing Address - Zip Code:90704-1658
Mailing Address - Country:US
Mailing Address - Phone:310-755-8469
Mailing Address - Fax:
Practice Address - Street 1:100 BANNING DR APT B8
Practice Address - Street 2:
Practice Address - City:AVALON
Practice Address - State:CA
Practice Address - Zip Code:90704-1658
Practice Address - Country:US
Practice Address - Phone:310-755-8469
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-02-16
Last Update Date:2023-02-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician