Healthcare Provider Details

I. General information

NPI: 1417325440
Provider Name (Legal Business Name): KAREN AFRE DIVINE CAA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2015
Last Update Date: 11/21/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1350 HICKORY ST SUITE 215
MELBOURNE FL
32901-3224
US

IV. Provider business mailing address

1775 W HIBISCUS BLVD SUITE 215
MELBOURNE FL
32901-2620
US

V. Phone/Fax

Practice location:
  • Phone: 321-837-3820
  • Fax: 321-837-3654
Mailing address:
  • Phone: 321-837-3820
  • Fax: 321-837-3654

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code367H00000X
TaxonomyAnesthesiologist Assistant
License NumberAA283
License Number StateFL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: