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General NPI Number Information
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NPI Number | 1245028521
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Entity Type | Individual
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Provider Name | MRS. RENEE PATRICE DIVINE
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Gender | Female
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Dates
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Enumeration Date | 04/28/2025
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Last Update Date | 04/28/2025
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Provider Practice Location Address
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Address Line | 1073 N BENSON RD
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City | FAIRFIELD
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State | CT
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Zip | 06824-5195
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Country | US
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Telephone | 203-254-4000
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Fax |
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Provider Business Mailing Address
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Address Line | 95 ROCKLAND AVE
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City | STRATFORD
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State | CT
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Zip | 06614-3117
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Country | US
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Telephone | 203-241-6739
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | NA
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License Number State | CT
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