Provider Demographics
NPI:1932741246
Name:LLANES, DIVINA GRACIA A
Entity Type:Individual
Prefix:
First Name:DIVINA GRACIA
Middle Name:A
Last Name:LLANES
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 1:1856 FOWLER AVE PH
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10462-3709
Mailing Address - Country:US
Mailing Address - Phone:917-773-2710
Mailing Address - Fax:
Practice Address - Street 1:1500 WATERS PL
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-2723
Practice Address - Country:US
Practice Address - Phone:929-348-3218
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-09
Last Update Date:2019-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY440292163WP0809X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0809XNursing Service ProvidersRegistered NursePsychiatric/Mental Health, Adult