Provider Demographics
NPI:1104251685
Name:DESTEFANO, MARIELLE (PA-C)
Entity type:Individual
Prefix:MISS
First Name:MARIELLE
Middle Name:
Last Name:DESTEFANO
Suffix:
Gender:F
Credentials:PA-C
Other - Prefix:MISS
Other - First Name:MARIELLE
Other - Middle Name:
Other - Last Name:GIBBONS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:PA-C
Mailing Address - Street 1:9910 FRANKLIN SQUARE DR STE 2110
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21236-4902
Mailing Address - Country:US
Mailing Address - Phone:410-933-6423
Mailing Address - Fax:
Practice Address - Street 1:4940 EASTERN AVE
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21224-2735
Practice Address - Country:US
Practice Address - Phone:410-550-0100
Practice Address - Fax:410-550-2899
Is Sole Proprietor?:No
Enumeration Date:2013-09-04
Last Update Date:2019-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant