Provider Demographics
NPI:1326835612
Name:DIVINE, VIXEN
Entity type:Individual
Prefix:
First Name:VIXEN
Middle Name:
Last Name:DIVINE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4805 LOCUST LN
Mailing Address - Street 2:
Mailing Address - City:HARRISBURG
Mailing Address - State:PA
Mailing Address - Zip Code:17109-4518
Mailing Address - Country:US
Mailing Address - Phone:717-877-4179
Mailing Address - Fax:
Practice Address - Street 1:4805 LOCUST LN
Practice Address - Street 2:
Practice Address - City:HARRISBURG
Practice Address - State:PA
Practice Address - Zip Code:17109-4518
Practice Address - Country:US
Practice Address - Phone:717-877-4179
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-04-22
Last Update Date:2025-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374J00000XNursing Service Related ProvidersDoula
No173C00000XOther Service ProvidersReflexologist
No225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist