Healthcare Provider Details

I. General information

NPI: 1417816612
Provider Name (Legal Business Name): DESTINY DANIELLE NELSON NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/21/2026
Last Update Date: 07/24/2026
Certification Date: 07/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

345 HUNTINGTON PLACE CT
MCDONOUGH GA
30253-8651
US

IV. Provider business mailing address

675 LAFAYETTE AVE APT 5112
FAYETTEVILLE GA
30214-8811
US

V. Phone/Fax

Practice location:
  • Phone: 678-782-6920
  • Fax:
Mailing address:
  • Phone: 337-335-7487
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN-NP712281
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: