Healthcare Provider Details

I. General information

NPI: 1346149820
Provider Name (Legal Business Name): DESTINY PATRICIA GRUTEL
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/02/2026
Last Update Date: 11/02/2026
Certification Date: 11/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

104 S MAPLE ST
WAYNE NE
68787-1627
US

IV. Provider business mailing address

6817 CRABAPPLE ST
LA VISTA NE
68128-4356
US

V. Phone/Fax

Practice location:
  • Phone: 999-999-9999
  • Fax:
Mailing address:
  • Phone: 402-999-2619
  • Fax: 402-999-2619

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code372600000X
TaxonomyAdult Companion
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: