Provider Demographics
NPI:1245033471
Name:DEVINE, SHANE BRENNA (DO)
Entity type:Individual
Prefix:
First Name:SHANE
Middle Name:BRENNA
Last Name:DEVINE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:88TH MEDICAL GROUP
Mailing Address - Street 2:4881 SUGAR MAPLE DR.
Mailing Address - City:WPAFB
Mailing Address - State:OH
Mailing Address - Zip Code:45433
Mailing Address - Country:US
Mailing Address - Phone:937-257-9926
Mailing Address - Fax:
Practice Address - Street 1:88TH MEDICAL GROUP
Practice Address - Street 2:4881 SUGAR MAPLE DR.
Practice Address - City:WPAFB
Practice Address - State:OH
Practice Address - Zip Code:45433
Practice Address - Country:US
Practice Address - Phone:937-257-0837
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-03-31
Last Update Date:2025-08-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH58.03828171000000X, 390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No171000000XOther Service ProvidersMilitary Health Care Provider