Provider Demographics
NPI:1417325440
Name:AFRE DIVINE, KAREN (CAA)
Entity Type:Individual
Prefix:MRS
First Name:KAREN
Middle Name:
Last Name:AFRE DIVINE
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
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Other - Last Name:
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Mailing Address - Street 1:1775 W HIBISCUS BLVD
Mailing Address - Street 2:SUITE 215
Mailing Address - City:MELBOURNE
Mailing Address - State:FL
Mailing Address - Zip Code:32901-2620
Mailing Address - Country:US
Mailing Address - Phone:321-837-3820
Mailing Address - Fax:321-837-3654
Practice Address - Street 1:1350 HICKORY ST
Practice Address - Street 2:SUITE 215
Practice Address - City:MELBOURNE
Practice Address - State:FL
Practice Address - Zip Code:32901-3224
Practice Address - Country:US
Practice Address - Phone:321-837-3820
Practice Address - Fax:321-837-3654
Is Sole Proprietor?:No
Enumeration Date:2015-09-08
Last Update Date:2016-11-21
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
FLAA283367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant