Provider Demographics
NPI:1144852385
Name:DESTEFANO, GRACE ANN
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:ANN
Last Name:DESTEFANO
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 1:107 CHAPEL AVE
Mailing Address - Street 2:
Mailing Address - City:EAST PATCHOGUE
Mailing Address - State:NY
Mailing Address - Zip Code:11772-5788
Mailing Address - Country:US
Mailing Address - Phone:631-827-9695
Mailing Address - Fax:
Practice Address - Street 1:32 GRAHAM AVE
Practice Address - Street 2:
Practice Address - City:CORTLAND
Practice Address - State:NY
Practice Address - Zip Code:13045-2452
Practice Address - Country:US
Practice Address - Phone:607-753-2011
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-02-05
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer