Provider Demographics
NPI:1821437468
Name:DEVINE, CORDELIA MARIE
Entity Type:Individual
Prefix:
First Name:CORDELIA
Middle Name:MARIE
Last Name:DEVINE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:DIDI
Other - Middle Name:
Other - Last Name:MARIE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:3500 GREENWOOD AVE
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40211-1615
Mailing Address - Country:US
Mailing Address - Phone:502-715-3369
Mailing Address - Fax:
Practice Address - Street 1:1100 ENVOY CIR
Practice Address - Street 2:SUITE 1105
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40299-1960
Practice Address - Country:US
Practice Address - Phone:502-715-3369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2013-06-17
Last Update Date:2013-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KY202434174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist