Provider Demographics
NPI:1356858435
Name:DEVINE, ELIZABETH (RN)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:
Last Name:DEVINE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:261 GRAND CENTRAL AVE
Mailing Address - Street 2:
Mailing Address - City:AMITYVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11701-3708
Mailing Address - Country:US
Mailing Address - Phone:631-559-7587
Mailing Address - Fax:
Practice Address - Street 1:261 GRAND CENTRAL AVE
Practice Address - Street 2:
Practice Address - City:AMITYVILLE
Practice Address - State:NY
Practice Address - Zip Code:11701-3708
Practice Address - Country:US
Practice Address - Phone:631-559-7587
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-01-10
Last Update Date:2018-01-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY261029-1163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYFZ76667YMedicaid