Provider Demographics
NPI:1013238955
Name:DEVINE, MARY (CNM)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:DEVINE
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4301 W MARKHAM ST # 783
Mailing Address - Street 2:
Mailing Address - City:LITTLE ROCK
Mailing Address - State:AR
Mailing Address - Zip Code:72205-7101
Mailing Address - Country:US
Mailing Address - Phone:501-686-8000
Mailing Address - Fax:501-280-3333
Practice Address - Street 1:4301 W MARKHAM ST # 783
Practice Address - Street 2:
Practice Address - City:LITTLE ROCK
Practice Address - State:AR
Practice Address - Zip Code:72205-7101
Practice Address - Country:US
Practice Address - Phone:501-686-8000
Practice Address - Fax:501-280-3333
Is Sole Proprietor?:No
Enumeration Date:2006-10-13
Last Update Date:2011-01-07
Deactivation Date:2010-06-10
Deactivation Code:
Reactivation Date:2010-06-15
Provider Licenses
StateLicense IDTaxonomies
ARCNM1006367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
AR134995799Medicaid
S58889Medicare UPIN
AR134995799Medicaid