Provider Demographics
NPI:1336591049
Name:DIVINE, AMANDA GAIL (NURSE)
Entity Type:Individual
Prefix:
First Name:AMANDA
Middle Name:GAIL
Last Name:DIVINE
Suffix:
Gender:F
Credentials:NURSE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8725 E 32ND ST N
Mailing Address - Street 2:
Mailing Address - City:WICHITA
Mailing Address - State:KS
Mailing Address - Zip Code:67226-4008
Mailing Address - Country:US
Mailing Address - Phone:316-201-1202
Mailing Address - Fax:316-201-1251
Practice Address - Street 1:8725 E 32ND ST N
Practice Address - Street 2:
Practice Address - City:WICHITA
Practice Address - State:KS
Practice Address - Zip Code:67226-4008
Practice Address - Country:US
Practice Address - Phone:316-201-1202
Practice Address - Fax:316-201-1251
Is Sole Proprietor?:No
Enumeration Date:2016-07-06
Last Update Date:2020-03-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KS53-78308-011363LP0200X
MO2016013652363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics