Provider Demographics
NPI:1831909217
Name:DIVITA, ALEXANDRA (STUDENT)
Entity type:Individual
Prefix:
First Name:ALEXANDRA
Middle Name:
Last Name:DIVITA
Suffix:
Gender:F
Credentials:STUDENT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:60 OLDE FARM RD
Mailing Address - Street 2:
Mailing Address - City:ONA
Mailing Address - State:WV
Mailing Address - Zip Code:25545-9747
Mailing Address - Country:US
Mailing Address - Phone:304-521-8183
Mailing Address - Fax:
Practice Address - Street 1:1542 SPRING VALLEY DR
Practice Address - Street 2:
Practice Address - City:HUNTINGTON
Practice Address - State:WV
Practice Address - Zip Code:25704-9501
Practice Address - Country:US
Practice Address - Phone:304-696-6035
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-01-08
Last Update Date:2025-01-08
Deactivation Date:
Deactivation Code:
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Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant