Provider Demographics
NPI:1306874904
Name:DIVINAGRACIA, ELMA (CRNA)
Entity type:Individual
Prefix:
First Name:ELMA
Middle Name:
Last Name:DIVINAGRACIA
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:68 S. SERVICE RD
Mailing Address - Street 2:SUITE 350
Mailing Address - City:MELVILLE
Mailing Address - State:NY
Mailing Address - Zip Code:11747-2358
Mailing Address - Country:US
Mailing Address - Phone:516-945-3115
Mailing Address - Fax:516-945-3131
Practice Address - Street 1:3249 OAK PARK AVE
Practice Address - Street 2:ANESTHESIA DEPARTMENT
Practice Address - City:BERWYN
Practice Address - State:IL
Practice Address - Zip Code:60402-3429
Practice Address - Country:US
Practice Address - Phone:708-783-3667
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-30
Last Update Date:2016-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041167282367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
ILIL72000031Medicare PIN