MEDICARE: DESTINY MAESTAS

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	163WL0100X	Lactation Consultant (Registered Nurse)	65701	NM

General Provider Information

NPI Number	:	1598615064
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINY MAESTAS

Provider Business Mailing Address
First Line	:	1003 S PRINCE DR
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2664
Country	:	US
Telephone Number	:	505-901-2805
Fax Number	:

Provider Business Practice Location Address
First Line	:	1003 S PRINCE DR
Second Line	:
City	:	ESPANOLA
State	:	NM
Zip	:	87532-2664
Country	:	US
Telephone Number	:	505-901-2805
Fax Number	:

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

Provider Enumeration Date	:	02/02/2026
Last Update Date	:	02/02/2026

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Directions to “ DESTINY MAESTAS ” Practice Location

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