Provider Demographics
NPI:1437972056
Name:BROICH, DIVINE GRACE FERNANDEZ
Entity type:Individual
Prefix:
First Name:DIVINE
Middle Name:GRACE FERNANDEZ
Last Name:BROICH
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1276 COCO CT
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92506-5560
Mailing Address - Country:US
Mailing Address - Phone:208-570-7440
Mailing Address - Fax:
Practice Address - Street 1:1276 COCO CT
Practice Address - Street 2:
Practice Address - City:RIVERSIDE
Practice Address - State:CA
Practice Address - Zip Code:92506-5560
Practice Address - Country:US
Practice Address - Phone:208-570-7440
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-04
Last Update Date:2024-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95396171163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse