Provider Demographics
NPI:1760766208
Name:DEVINE, WILLIAM FRANCIS (PMHNP-BC)
Entity Type:Individual
Prefix:MR
First Name:WILLIAM
Middle Name:FRANCIS
Last Name:DEVINE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:166 CHRISTINA MARIE DR
Mailing Address - Street 2:
Mailing Address - City:O FALLON
Mailing Address - State:MO
Mailing Address - Zip Code:63368-7872
Mailing Address - Country:US
Mailing Address - Phone:314-443-9228
Mailing Address - Fax:
Practice Address - Street 1:2187 SWANSON AVE
Practice Address - Street 2:
Practice Address - City:LAKE HAVASU CITY
Practice Address - State:AZ
Practice Address - Zip Code:86403-6838
Practice Address - Country:US
Practice Address - Phone:928-855-3432
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-03
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2008006146163W00000X
MO2018025246363LP0808X
AZ229481363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ498748Medicaid