Provider Demographics
NPI:1538892559
Name:LANDRY, DESTINY L
Entity type:Individual
Prefix:
First Name:DESTINY
Middle Name:L
Last Name:LANDRY
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 1:5520 JOHNSON ST
Mailing Address - Street 2:STE K PMB 1121
Mailing Address - City:LAFAYETTE
Mailing Address - State:LA
Mailing Address - Zip Code:70503-2212
Mailing Address - Country:US
Mailing Address - Phone:337-417-9948
Mailing Address - Fax:
Practice Address - Street 1:109 BOULET DR
Practice Address - Street 2:
Practice Address - City:LAFAYETTE
Practice Address - State:LA
Practice Address - Zip Code:70506-2212
Practice Address - Country:US
Practice Address - Phone:337-230-3116
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-07
Last Update Date:2023-09-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
174400000X, 224P00000X, 174400000X
LA225000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
No224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No225000000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOrthotic Fitter