Healthcare Provider Details

I. General information

NPI: 1780219410
Provider Name (Legal Business Name): COURTNEY DESTEFANO
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/03/2020
Last Update Date: 08/11/2026
Certification Date: 08/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5 GREENTREE CENTER SUITE 117
MARLTON NJ
08053-3422
US

IV. Provider business mailing address

2418 E YORK ST
PHILADELPHIA PA
19125-3006
US

V. Phone/Fax

Practice location:
  • Phone: 856-528-7082
  • Fax:
Mailing address:
  • Phone: 267-887-0013
  • Fax: 215-392-7992

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ01015900
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: