Provider Demographics
NPI:1013481316
Name:DIVINCENZO, RAQUEL MARIE
Entity Type:Individual
Prefix:
First Name:RAQUEL
Middle Name:MARIE
Last Name:DIVINCENZO
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5151 PARK AVE # MC1425
Mailing Address - Street 2:
Mailing Address - City:FAIRFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06825-1090
Mailing Address - Country:US
Mailing Address - Phone:845-531-9572
Mailing Address - Fax:
Practice Address - Street 1:5151 PARK AVE # MC1425
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06825-1090
Practice Address - Country:US
Practice Address - Phone:845-531-9572
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-20
Last Update Date:2019-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY82100177502OtherMVP HEALTH CARE