Provider Demographics
NPI:1558672162
Name:DIVINE, KYLIE MARIE (OD)
Entity Type:Individual
Prefix:
First Name:KYLIE
Middle Name:MARIE
Last Name:DIVINE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1347 N WESTWOOD BLVD
Mailing Address - Street 2:
Mailing Address - City:POPLAR BLUFF
Mailing Address - State:MO
Mailing Address - Zip Code:63901-3313
Mailing Address - Country:US
Mailing Address - Phone:573-712-2333
Mailing Address - Fax:573-712-2433
Practice Address - Street 1:1347 NORTH WESTWOOD BLVD.
Practice Address - Street 2:
Practice Address - City:POPLAR BLUFF
Practice Address - State:MO
Practice Address - Zip Code:63901
Practice Address - Country:US
Practice Address - Phone:573-712-2333
Practice Address - Fax:573-712-2433
Is Sole Proprietor?:No
Enumeration Date:2010-06-29
Last Update Date:2017-01-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2010020558152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist