Provider Demographics
NPI:1407147838
Name:DIVITA-MCKENNA, CHRISTINE LYNN (RPAC)
Entity Type:Individual
Prefix:MISS
First Name:CHRISTINE
Middle Name:LYNN
Last Name:DIVITA-MCKENNA
Suffix:
Gender:F
Credentials:RPAC
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:1150 YOUNGS RD
Mailing Address - Street 2:SUITE 104
Mailing Address - City:WILLIAMSVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:14221-8053
Mailing Address - Country:US
Mailing Address - Phone:716-636-7979
Mailing Address - Fax:716-636-7993
Practice Address - Street 1:1150 YOUNGS RD
Practice Address - Street 2:SUITE 104
Practice Address - City:WILLIAMSVILLE
Practice Address - State:NY
Practice Address - Zip Code:14221-8053
Practice Address - Country:US
Practice Address - Phone:716-636-7979
Practice Address - Fax:716-636-7993
Is Sole Proprietor?:No
Enumeration Date:2011-04-19
Last Update Date:2016-10-25
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NY014729363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYJ400087601Medicare PIN