Healthcare Provider Details

I. General information

NPI: 1407849425
Provider Name (Legal Business Name): VANNA M DEST APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/24/2005
Last Update Date: 08/06/2026
Certification Date: 08/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4185 BLACK ROCK TPKE
FAIRFIELD CT
06824-1841
US

IV. Provider business mailing address

4185 BLACK ROCK TPKE
FAIRFIELD CT
06824-1841
US

V. Phone/Fax

Practice location:
  • Phone: 475-422-3525
  • Fax: 203-254-1191
Mailing address:
  • Phone: 475-422-3525
  • Fax: 203-254-1191

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number001635
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number001635
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: