Basic Information
Provider Information | |||||||||
NPI: | 1336554997 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | DEVINE | ||||||||
FirstName: | DONNA | ||||||||
MiddleName: | REBECCA | ||||||||
NamePrefix: | MS. | ||||||||
NameSuffix: |   | ||||||||
Credential: | MSN, FNP-C | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: | DEVINE | ||||||||
OtherFirstName: | DONNA | ||||||||
OtherMiddleName: | REBECCA | ||||||||
OtherNamePrefix: | MS. | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: | NP | ||||||||
OtherLastNameType: | 2 | ||||||||
Mailing Information | |||||||||
Address1: | 5008 BRITTONFIELD PKWY STE 700 | ||||||||
Address2: |   | ||||||||
City: | EAST SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 130579249 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154727504 | ||||||||
FaxNumber: | 3156344677 | ||||||||
Practice Location | |||||||||
Address1: | 5008 BRITTONFIELD PKWY STE 700 | ||||||||
Address2: |   | ||||||||
City: | EAST SYRACUSE | ||||||||
State: | NY | ||||||||
PostalCode: | 130579249 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 3154727504 | ||||||||
FaxNumber: | 3156344677 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 06/23/2014 | ||||||||
LastUpdateDate: | 05/26/2020 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | Y | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: | 05/26/2020 |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | F338759 | NY | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   |
ID Information
ID | Type | State | Issuer | Description | MD3256597 | 01 |   | DEA | OTHER |