Provider Demographics
NPI:1609600857
Name:VILLASENOR, DESTINY
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:
Last Name:VILLASENOR
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 1:11188 ANDERSON ST FL 2
Mailing Address - Street 2:
Mailing Address - City:LOMA LINDA
Mailing Address - State:CA
Mailing Address - Zip Code:92354-2833
Mailing Address - Country:US
Mailing Address - Phone:909-558-1000
Mailing Address - Fax:
Practice Address - Street 1:11188 ANDERSON ST FL 2
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2833
Practice Address - Country:US
Practice Address - Phone:909-558-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-29
Last Update Date:2024-09-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker