Basic Information
| Provider Information | |||||||||
| NPI: | 1174720874 | ||||||||
| EntityType: | 2 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | DESTIN PLASTIC SURGERY | ||||||||
| LastName: | |||||||||
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| OtherOrganizationName: | |||||||||
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| Mailing Information | |||||||||
| Address1: | 4485 FURLING LN | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325415331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506541194 | ||||||||
| FaxNumber: | 8503371698 | ||||||||
| Practice Location | |||||||||
| Address1: | 4485 FURLING LN | ||||||||
| Address2: | |||||||||
| City: | DESTIN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 325415331 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8506541194 | ||||||||
| FaxNumber: | 8503371698 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 06/27/2007 | ||||||||
| LastUpdateDate: | 08/22/2020 | ||||||||
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| ProviderGenderCode: | |||||||||
| AuthorizedOfficialLastName: | SENN | ||||||||
| AuthorizedOfficialFirstName: | BRANDIE | ||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | OFFICE STAFF | ||||||||
| AuthorizedOfficialTelephone: | 8506507606 | ||||||||
| IsSoleProprietor: | |||||||||
| IsOrganizationSubpart: | N | ||||||||
| ParentOrganizationLBN: | |||||||||
| AuthorizedOfficialNamePrefix: | MRS. | ||||||||
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| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 174400000X | FL | Y | 193400000X SINGLE SPECIALTY GROUP | Other Service Providers | Specialist |
No ID Information.