Basic Information
| Provider Information | |||||||||
| NPI: | 1215218292 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DEVINE | ||||||||
| FirstName: | ANJANETTE | ||||||||
| MiddleName: | MICHELLE | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | FNP | ||||||||
| OtherOrganizationName: | |||||||||
| OtherOrganizationType: | |||||||||
| OtherLastName: | JACKSON | ||||||||
| OtherFirstName: | ANJANETTE | ||||||||
| OtherMiddleName: | MICHELLE | ||||||||
| OtherNamePrefix: | MS. | ||||||||
| OtherNameSuffix: | |||||||||
| OtherCredential: | FNP | ||||||||
| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | PO BOX 490 | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976240490 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5417833273 | ||||||||
| Practice Location | |||||||||
| Address1: | 330 S CHILOQUIN BLVD | ||||||||
| Address2: | |||||||||
| City: | CHILOQUIN | ||||||||
| State: | OR | ||||||||
| PostalCode: | 976246747 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5418821487 | ||||||||
| FaxNumber: | 5417833273 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/02/2011 | ||||||||
| LastUpdateDate: | 03/15/2017 | ||||||||
| NPIDeactivationReasonCode: | |||||||||
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| NPIReactivationDate: | |||||||||
| ProviderGenderCode: | F | ||||||||
| AuthorizedOfficialLastName: | |||||||||
| AuthorizedOfficialFirstName: | |||||||||
| AuthorizedOfficialMiddleName: | |||||||||
| AuthorizedOfficialTitleorPosition: | |||||||||
| AuthorizedOfficialTelephone: | |||||||||
| IsSoleProprietor: | N | ||||||||
| IsOrganizationSubpart: | |||||||||
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| AuthorizedOfficialCredential: | |||||||||
| NPICertificationDate: | |||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | R874930 | MS | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
No ID Information.