Provider Demographics
NPI:1861148603
Name:DIVINE, ASHLEY NICOLE (APRN)
Entity type:Individual
Prefix:MRS
First Name:ASHLEY
Middle Name:NICOLE
Last Name:DIVINE
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:ASHLEY
Other - Middle Name:N
Other - Last Name:WILLIAMS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:920 W. PRAIRIE DR.
Mailing Address - Street 2:SUITE J
Mailing Address - City:SYCAMORE
Mailing Address - State:IL
Mailing Address - Zip Code:60178
Mailing Address - Country:US
Mailing Address - Phone:815-895-3354
Mailing Address - Fax:815-895-3345
Practice Address - Street 1:920 W. PRAIRIE DR.
Practice Address - Street 2:SUITE J
Practice Address - City:SYCAMORE
Practice Address - State:IL
Practice Address - Zip Code:60178
Practice Address - Country:US
Practice Address - Phone:815-895-3354
Practice Address - Fax:815-895-3345
Is Sole Proprietor?:No
Enumeration Date:2022-03-01
Last Update Date:2025-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041392233163W00000X
IL209025054363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse