Provider Demographics
NPI:1376898916
Name:DIVICO, LINDA LOUISE (RN)
Entity Type:Individual
Prefix:MRS
First Name:LINDA
Middle Name:LOUISE
Last Name:DIVICO
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 1:4422 E COLUMBUS DR
Mailing Address - Street 2:
Mailing Address - City:TAMPA
Mailing Address - State:FL
Mailing Address - Zip Code:33605-3233
Mailing Address - Country:US
Mailing Address - Phone:813-493-1078
Mailing Address - Fax:813-621-9373
Practice Address - Street 1:4422 E COLUMBUS DR
Practice Address - Street 2:
Practice Address - City:TAMPA
Practice Address - State:FL
Practice Address - Zip Code:33605-3233
Practice Address - Country:US
Practice Address - Phone:813-493-1078
Practice Address - Fax:813-621-9373
Is Sole Proprietor?:Yes
Enumeration Date:2012-07-19
Last Update Date:2012-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDRN9211815163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse