Provider Demographics
NPI:1225833791
Name:DESTEFANO, NATALIE ROSE (PT, DPT)
Entity type:Individual
Prefix:
First Name:NATALIE
Middle Name:ROSE
Last Name:DESTEFANO
Suffix:
Gender:
Credentials:PT, DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4504 W SPRUCE ST APT APT 627
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33607-5789
Mailing Address - Country:US
Mailing Address - Phone:732-567-9154
Mailing Address - Fax:
Practice Address - Street 1:13801 BRUCE B DOWNS BLVD STE 303
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33613-3939
Practice Address - Country:US
Practice Address - Phone:813-979-4819
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-18
Last Update Date:2025-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL42818225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist