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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Other - Last Name:
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Mailing Address - Street 1:160 E ARTESIA ST
Mailing Address - Street 2:STE 255
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91767-2921
Mailing Address - Country:US
Mailing Address - Phone:949-586-3200
Mailing Address - Fax:
Practice Address - Street 1:24331 EL TORO RD STE 200
Practice Address - Street 2:
Practice Address - City:LAGUNA WOODS
Practice Address - State:CA
Practice Address - Zip Code:92637-3116
Practice Address - Country:US
Practice Address - Phone:949-586-3200
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-07-19
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
CA60085363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant