Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 207N00000X | Dermatologist | OS 10179 | FL |
NPI | 1003145087 |
---|---|
Provider Name | Dr. Laura Destefano |
First Address | Port Charlotte, FL 33952-5306 |
Second Address | Port Charlotte, FL 33952-5306 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 21/12/2009 |
Last Update Date | 17/03/2016 |