Basic Information
| Provider Information | |||||||||
| NPI: | 1275122020 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | DIVINO | ||||||||
| FirstName: | CARLY | ||||||||
| MiddleName: | ANN | ||||||||
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| Mailing Information | |||||||||
| Address1: | 24436 MUELA | ||||||||
| Address2: | |||||||||
| City: | MISSION VIEJO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 926922218 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 1207 E FRUIT ST | ||||||||
| Address2: | |||||||||
| City: | SANTA ANA | ||||||||
| State: | CA | ||||||||
| PostalCode: | 927014206 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7149539373 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 01/15/2021 | ||||||||
| LastUpdateDate: | 01/15/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 01/15/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 164X00000X | 693502 | CA | Y | Nursing Service Providers | Licensed Vocational Nurse |
No ID Information.