Provider Demographics
NPI:1376559492
Name:DIVENERE, DEBRA M (APRN, CPNP)
Entity Type:Individual
Prefix:MS
First Name:DEBRA
Middle Name:M
Last Name:DIVENERE
Suffix:
Gender:F
Credentials:APRN, CPNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:25 WINSTON CT
Mailing Address - Street 2:
Mailing Address - City:BRISTOL
Mailing Address - State:CT
Mailing Address - Zip Code:06010-2691
Mailing Address - Country:US
Mailing Address - Phone:860-585-7063
Mailing Address - Fax:
Practice Address - Street 1:134 GRANDVIEW AVE
Practice Address - Street 2:SUITE 208
Practice Address - City:WATERBURY
Practice Address - State:CT
Practice Address - Zip Code:06708-2507
Practice Address - Country:US
Practice Address - Phone:203-755-3279
Practice Address - Fax:203-755-3057
Is Sole Proprietor?:No
Enumeration Date:2006-07-31
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT0002590363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004224036Medicaid
CT500000866Medicare ID - Type Unspecified
CT004224036Medicaid