Provider Demographics
NPI:1386319762
Name:NEVAREZ, DESTINY BREANA RAE
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:BREANA RAE
Last Name:NEVAREZ
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 1:110 GATEWAY DR STE 210
Mailing Address - Street 2:
Mailing Address - City:LINCOLN
Mailing Address - State:CA
Mailing Address - Zip Code:95648-3306
Mailing Address - Country:US
Mailing Address - Phone:916-645-3300
Mailing Address - Fax:916-645-3311
Practice Address - Street 1:110 GATEWAY DR STE 210
Practice Address - Street 2:
Practice Address - City:LINCOLN
Practice Address - State:CA
Practice Address - Zip Code:95648-3306
Practice Address - Country:US
Practice Address - Phone:916-645-3300
Practice Address - Fax:916-645-3311
Is Sole Proprietor?:Yes
Enumeration Date:2021-08-09
Last Update Date:2021-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator