Provider Demographics
NPI:1790722684
Name:DIVERTIE, VIKY (ARNP)
Entity Type:Individual
Prefix:
First Name:VIKY
Middle Name:
Last Name:DIVERTIE
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 1:8711 PERIMETER PARK BLVD
Mailing Address - Street 2:SUITE 6
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32216-6388
Mailing Address - Country:US
Mailing Address - Phone:904-223-2330
Mailing Address - Fax:904-223-3149
Practice Address - Street 1:12303 SAN JOSE BLVD
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32223-2640
Practice Address - Country:US
Practice Address - Phone:904-288-0277
Practice Address - Fax:904-288-0414
Is Sole Proprietor?:No
Enumeration Date:2006-06-01
Last Update Date:2010-09-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP2180342363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE1343XMedicare PIN
S65122Medicare UPIN
FLE1343Medicare PIN