Provider Demographics
NPI:1306292354
Name:DESTIGTER, POLLY CAROLE
Entity type:Individual
Prefix:
First Name:POLLY
Middle Name:CAROLE
Last Name:DESTIGTER
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 1:515 MADISON AVE SE
Mailing Address - Street 2:
Mailing Address - City:GRAND RAPIDS
Mailing Address - State:MI
Mailing Address - Zip Code:49503-5313
Mailing Address - Country:US
Mailing Address - Phone:616-648-8899
Mailing Address - Fax:
Practice Address - Street 1:515 MADISON AVE SE
Practice Address - Street 2:
Practice Address - City:GRAND RAPIDS
Practice Address - State:MI
Practice Address - Zip Code:49503-5313
Practice Address - Country:US
Practice Address - Phone:616-648-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-09
Last Update Date:2016-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other