Provider Demographics
NPI:1306366729
Name:MILLER-MANCUSO, DESTINY M (MD)
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:M
Last Name:MILLER-MANCUSO
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:DESTINY
Other - Middle Name:M
Other - Last Name:MILLER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:714 LINCOLN ST. NE
Mailing Address - Street 2:
Mailing Address - City:LE MARS
Mailing Address - State:IA
Mailing Address - Zip Code:51031-3314
Mailing Address - Country:US
Mailing Address - Phone:712-546-3492
Mailing Address - Fax:712-546-3352
Practice Address - Street 1:714 LINCOLN ST. NE
Practice Address - Street 2:
Practice Address - City:LE MARS
Practice Address - State:IA
Practice Address - Zip Code:51031-3314
Practice Address - Country:US
Practice Address - Phone:712-546-3492
Practice Address - Fax:712-546-3352
Is Sole Proprietor?:No
Enumeration Date:2017-06-27
Last Update Date:2022-08-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAR-11054207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine