Healthcare Provider Details

I. General information

NPI: 1114285962
Provider Name (Legal Business Name): ANDREA LYNN DESTORIES M.D.
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/30/2012
Last Update Date: 04/09/2020
Certification Date: 04/09/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1240 E 9TH ST
RENO NV
89512-2964
US

IV. Provider business mailing address

1340 E. 9TH ST.
RENO NV
89512
US

V. Phone/Fax

Practice location:
  • Phone: 775-323-0478
  • Fax:
Mailing address:
  • Phone: 775-323-0478
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License Number34944264
License Number StateNV
# 2
Primary TaxonomyY
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberMD6088082
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: