Provider Demographics
NPI:1265945620
Name:DEVINE, RAECHEL (AGNP-BC)
Entity type:Individual
Prefix:
First Name:RAECHEL
Middle Name:
Last Name:DEVINE
Suffix:
Gender:F
Credentials:AGNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:90 PRESIDENTIAL PLZ
Mailing Address - Street 2:
Mailing Address - City:SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13202-2240
Mailing Address - Country:US
Mailing Address - Phone:315-464-4686
Mailing Address - Fax:
Practice Address - Street 1:90 PRESIDENTIAL PLAZA
Practice Address - Street 2:
Practice Address - City:SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13202
Practice Address - Country:US
Practice Address - Phone:315-464-4686
Practice Address - Fax:315-464-7106
Is Sole Proprietor?:No
Enumeration Date:2017-11-08
Last Update Date:2021-01-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF308436-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health