Provider Demographics
NPI:1043883093
Name:DIVINE, LILA T (PA)
Entity type:Individual
Prefix:MS
First Name:LILA
Middle Name:T
Last Name:DIVINE
Suffix:
Gender:F
Credentials:PA
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Mailing Address - Street 1:PO BOX 60447
Mailing Address - Street 2:
Mailing Address - City:CHARLOTTE
Mailing Address - State:NC
Mailing Address - Zip Code:28260-0447
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:10905 PROVIDENCE RD W STE 270
Practice Address - Street 2:
Practice Address - City:CHARLOTTE
Practice Address - State:NC
Practice Address - Zip Code:28277-1538
Practice Address - Country:US
Practice Address - Phone:704-316-3410
Practice Address - Fax:704-316-3420
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2025-07-31
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA60085363A00000X
NC0010-14463363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant