Provider Demographics
NPI:1427619675
Name:BUCCELLATO, DIVINA G (NP)
Entity type:Individual
Prefix:
First Name:DIVINA
Middle Name:G
Last Name:BUCCELLATO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3040 COLORADO COVE
Mailing Address - Street 2:
Mailing Address - City:SAN ANTONIO
Mailing Address - State:TX
Mailing Address - Zip Code:78253
Mailing Address - Country:US
Mailing Address - Phone:203-228-8485
Mailing Address - Fax:
Practice Address - Street 1:3070 COLORADO CV
Practice Address - Street 2:
Practice Address - City:SAN ANTONIO
Practice Address - State:TX
Practice Address - Zip Code:78253-6294
Practice Address - Country:US
Practice Address - Phone:203-228-8485
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-06-27
Last Update Date:2023-12-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX141736363L00000X, 363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner