Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 111NN0400X | Neurology | 038013513 | IL |
NPI | 1376175893 |
---|---|
Provider Name | Dr. Lauren Destephano |
First Address | Spring Grove, IL 60081-8308 |
Second Address | Spring Grove, IL 60081-8308 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | No |
Is Organization Subpart | N/A |
Enumeration Date | 12/02/2020 |
Last Update Date | 12/02/2020 |