Healthcare Provider Details

I. General information

NPI: 1699691717
Provider Name (Legal Business Name): DESTINIA LASHAWN BRISTER
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

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

III. Provider practice location address

2550 TRADE CENTER DR
EVANS GA
30809-6167
US

IV. Provider business mailing address

3611 WALKER CREEK RD
HEPHZIBAH GA
30815-5168
US

V. Phone/Fax

Practice location:
  • Phone: 706-723-8458
  • Fax:
Mailing address:
  • Phone: 706-804-6185
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: