Provider Demographics
NPI:1205190105
Name:DEVINE, MICHELLE ELIZABETH
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:ELIZABETH
Last Name:DEVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MICHELLE
Other - Middle Name:ELIZABETH
Other - Last Name:BOYLE
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1548 JULIA GOLDBACH AVE
Mailing Address - Street 2:
Mailing Address - City:BOHEMIA
Mailing Address - State:NY
Mailing Address - Zip Code:11716-1506
Mailing Address - Country:US
Mailing Address - Phone:631-672-2309
Mailing Address - Fax:
Practice Address - Street 1:4 FERN PL
Practice Address - Street 2:
Practice Address - City:PLAINVIEW
Practice Address - State:NY
Practice Address - Zip Code:11803-4725
Practice Address - Country:US
Practice Address - Phone:516-933-4700
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-26
Last Update Date:2012-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY2121310174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist