Provider Demographics
NPI:1144633140
Name:DIVINE, ERICA MARIE (LPN)
Entity type:Individual
Prefix:
First Name:ERICA
Middle Name:MARIE
Last Name:DIVINE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14095 SW WALKER RD APT 144
Mailing Address - Street 2:
Mailing Address - City:BEAVERTON
Mailing Address - State:OR
Mailing Address - Zip Code:97005-1075
Mailing Address - Country:US
Mailing Address - Phone:503-415-1741
Mailing Address - Fax:
Practice Address - Street 1:14095 SW WALKER RD APT 144
Practice Address - Street 2:
Practice Address - City:BEAVERTON
Practice Address - State:OR
Practice Address - Zip Code:97005-1075
Practice Address - Country:US
Practice Address - Phone:503-415-1741
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-06-06
Last Update Date:2014-06-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR201230646LPN164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse