Provider Demographics
NPI:1588164776
Name:JUNIOR, DESTINY NIA (LPN)
Entity type:Individual
Prefix:MISS
First Name:DESTINY
Middle Name:NIA
Last Name:JUNIOR
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:441 N MONTFORD AVE
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21224-1018
Mailing Address - Country:US
Mailing Address - Phone:443-642-1013
Mailing Address - Fax:
Practice Address - Street 1:4801 LIBERTY HEIGHTS AVE
Practice Address - Street 2:
Practice Address - City:GWYNN OAK
Practice Address - State:MD
Practice Address - Zip Code:21207-7157
Practice Address - Country:US
Practice Address - Phone:410-733-4636
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-02-14
Last Update Date:2018-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDLP45111164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse