Healthcare Provider Details

I. General information

NPI: 1831939537
Provider Name (Legal Business Name): DESTINY DENAE MCKNIGHT
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/30/2024
Last Update Date: 07/09/2026
Certification Date: 07/09/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2300 173RD ST
HAMMOND IN
46323-2076
US

IV. Provider business mailing address

362 W 127TH AVE
CROWN POINT IN
46307-7976
US

V. Phone/Fax

Practice location:
  • Phone: 708-261-6409
  • Fax:
Mailing address:
  • Phone: 708-261-6409
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License Number36004193A
License Number StateIN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: