Provider Demographics
NPI:1629213509
Name:DEVINE, TERI A (ARNP)
Entity Type:Individual
Prefix:MRS
First Name:TERI
Middle Name:A
Last Name:DEVINE
Suffix:
Gender:F
Credentials:ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4700 E 56TH ST STE 100
Mailing Address - Street 2:
Mailing Address - City:DAVENPORT
Mailing Address - State:IA
Mailing Address - Zip Code:52807-2904
Mailing Address - Country:US
Mailing Address - Phone:563-421-0480
Mailing Address - Fax:563-421-0489
Practice Address - Street 1:4700 E 56TH ST STE 100
Practice Address - Street 2:
Practice Address - City:DAVENPORT
Practice Address - State:IA
Practice Address - Zip Code:52807-2904
Practice Address - Country:US
Practice Address - Phone:563-421-0480
Practice Address - Fax:563-421-0489
Is Sole Proprietor?:No
Enumeration Date:2008-12-08
Last Update Date:2021-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI4642-33363L00000X
IAL-092807363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IA1629213509Medicaid