MEDICARE: DESTINI BLANCHE GONYON LPN

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	164W00000X	Licensed Practical Nurse	76069	TN

General Provider Information

NPI Number	:	1720412752
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DESTINI BLANCHE GONYON LPN

Provider Business Mailing Address
First Line	:	2891 KNOB CREEK RD
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-1437
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	2891 KNOB CREEK RD
Second Line	:
City	:	COLUMBIA
State	:	TN
Zip	:	38401-1437
Country	:	US
Telephone Number	:	931-797-8744
Fax Number	:

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

Provider Enumeration Date	:	08/27/2013
Last Update Date	:	08/27/2013

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