=====================================================
General NPI Number Information
=====================================================
NPI Number | 1932741246
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | DIVINA GRACIA A LLANES
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/09/2019
-----------------------------------------------------
Last Update Date | 10/09/2019
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 1500 WATERS PL
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10461-2723
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 929-348-3218
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1856 FOWLER AVE PH
-----------------------------------------------------
City | BRONX
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10462-3709
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 917-773-2710
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 163WP0809X
-----------------------------------------------------
Taxonomy Name | Adult Psychiatric/Mental Health Registered Nurse
-----------------------------------------------------
License Number | 440292
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------