Provider Demographics
NPI:1245028521
Name:DIVINE, RENEE PATRICE
Entity type:Individual
Prefix:MRS
First Name:RENEE
Middle Name:PATRICE
Last Name:DIVINE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:95 ROCKLAND AVE
Mailing Address - Street 2:
Mailing Address - City:STRATFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06614-3117
Mailing Address - Country:US
Mailing Address - Phone:203-241-6739
Mailing Address - Fax:
Practice Address - Street 1:1073 N BENSON RD
Practice Address - Street 2:
Practice Address - City:FAIRFIELD
Practice Address - State:CT
Practice Address - Zip Code:06824-5195
Practice Address - Country:US
Practice Address - Phone:203-254-4000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-28
Last Update Date:2025-04-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CTNA363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health