MEDICARE: DIVINE MOFOR FOMINKA

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	374U00000X	Home Health Aide	HHA200005765	DC

General Provider Information

NPI Number	:	1841154010
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DIVINE MOFOR FOMINKA

Provider Business Mailing Address
First Line	:	908 LAKE FRONT DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-2950
Country	:	US
Telephone Number	:	719-725-9850
Fax Number	:

Provider Business Practice Location Address
First Line	:	908 LAKE FRONT DR
Second Line	:
City	:	BOWIE
State	:	MD
Zip	:	20721-2950
Country	:	US
Telephone Number	:	719-725-9850
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	12/12/2025
Last Update Date	:	12/12/2025

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Directions to “ DIVINE MOFOR FOMINKA ” Practice Location

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