=====================================================
General NPI Number Information
=====================================================
NPI Number | 1215519038
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | A & S DIVINE HEALTHCARE SERVICES PLLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 04/21/2021
-----------------------------------------------------
Last Update Date | 11/16/2021
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1477 RING RD
-----------------------------------------------------
City | CALUMET CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60409-5459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-933-6346
-----------------------------------------------------
Fax | 708-933-6356
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1477 RING RD
-----------------------------------------------------
City | CALUMET CITY
-----------------------------------------------------
State | IL
-----------------------------------------------------
Zip | 60409-5459
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 708-933-6346
-----------------------------------------------------
Fax | 708-933-6356
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | CO-OWNER/FAMILY NURSE PRACTITIONER
-----------------------------------------------------
Name | DR. ANGEL WHITE
-----------------------------------------------------
Credential | DNP, APRN, FNP-BC
-----------------------------------------------------
Telephone | 708-933-6346
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LF0000X
-----------------------------------------------------
Taxonomy Name | Family Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------