Provider Demographics
NPI:1467653162
Name:DEVINE, SUSAN DIANE (TVI)
Entity Type:Individual
Prefix:MRS
First Name:SUSAN
Middle Name:DIANE
Last Name:DEVINE
Suffix:
Gender:F
Credentials:TVI
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:812 WRENWOOD DR
Mailing Address - Street 2:
Mailing Address - City:BOWLING GREEN
Mailing Address - State:KY
Mailing Address - Zip Code:42103-1582
Mailing Address - Country:US
Mailing Address - Phone:270-779-7564
Mailing Address - Fax:270-842-6011
Practice Address - Street 1:812 WRENWOOD DR
Practice Address - Street 2:
Practice Address - City:BOWLING GREEN
Practice Address - State:KY
Practice Address - Zip Code:42103-1582
Practice Address - Country:US
Practice Address - Phone:270-779-7564
Practice Address - Fax:270-842-6011
Is Sole Proprietor?:Yes
Enumeration Date:2007-05-30
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TNVISION CERTIFICATION174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist