MEDICARE: DESTINY CRUMBLE

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program	9642834	FL

General Provider Information

NPI Number	:	1295652360
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY CRUMBLE

Provider Business Mailing Address
First Line	:	2402 OLD MIDDLEBURG RD N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-3509
Country	:	US
Telephone Number	:	757-822-0454
Fax Number	:

Provider Business Practice Location Address
First Line	:	2402 OLD MIDDLEBURG RD N
Second Line	:
City	:	JACKSONVILLE
State	:	FL
Zip	:	32210-3509
Country	:	US
Telephone Number	:	757-822-0454
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	06/30/2026
Last Update Date	:	06/30/2026

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Directions to “ DESTINY CRUMBLE ” Practice Location

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