Provider Demographics
NPI:1346051067
Name:CARLSON, DESTINEE M
Entity type:Individual
Prefix:
First Name:DESTINEE
Middle Name:M
Last Name:CARLSON
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 1:510 WAYNE ST
Mailing Address - Street 2:
Mailing Address - City:COLUMBUS GROVE
Mailing Address - State:OH
Mailing Address - Zip Code:45830-1030
Mailing Address - Country:US
Mailing Address - Phone:419-388-6145
Mailing Address - Fax:
Practice Address - Street 1:510 WAYNE ST
Practice Address - Street 2:
Practice Address - City:COLUMBUS GROVE
Practice Address - State:OH
Practice Address - Zip Code:45830-1030
Practice Address - Country:US
Practice Address - Phone:419-388-6145
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-14
Last Update Date:2025-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH376J00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376J00000XNursing Service Related ProvidersHomemaker