Healthcare Provider Details

I. General information

NPI: 1740018514
Provider Name (Legal Business Name): WHITNEY DISTEFANO RN, NC-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 07/23/2024
Last Update Date: 07/23/2024
Certification Date: 07/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5412 IBIS CT
WILMINGTON NC
28409-2630
US

IV. Provider business mailing address

5412 IBIS CT
WILMINGTON NC
28409-2630
US

V. Phone/Fax

Practice location:
  • Phone: 910-934-1094
  • Fax:
Mailing address:
  • Phone: 910-934-1094
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number245536
License Number StateNC
# 2
Primary TaxonomyN
Taxonomy Code171400000X
TaxonomyHealth & Wellness Coach
License Number
License Number StateNULL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: