MEDICARE: DIVINE TELEHEALTH SERVICES LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner

General Provider Information

NPI Number	:	1750065025
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE TELEHEALTH SERVICES LLC

Provider Business Mailing Address
First Line	:	6982 LAKESIDE RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-2624
Country	:	US
Telephone Number	:	561-349-5001
Fax Number	:

Provider Business Practice Location Address
First Line	:	6982 LAKESIDE RD
Second Line	:
City	:	WEST PALM BEACH
State	:	FL
Zip	:	33411-2624
Country	:	US
Telephone Number	:	561-349-5001
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	LAVERNE MITCHELL
Credential	:	APRN
Telephone Number	:	561-349-5001

Provider Enumeration Date	:	06/14/2023
Last Update Date	:	06/14/2023

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Directions to “DIVINE TELEHEALTH SERVICES LLC ” Practice Location

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