Healthcare Provider Details

I. General information

NPI: 1558203877
Provider Name (Legal Business Name): DIVINE NKONGHO
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/07/2026
Last Update Date: 04/07/2026
Certification Date: 04/07/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7833 RIVERDALE RD
NEW CARROLLTON MD
20784-4017
US

IV. Provider business mailing address

7833 RIVERDALE RD
NEW CARROLLTON MD
20784-4017
US

V. Phone/Fax

Practice location:
  • Phone: 240-945-6121
  • Fax:
Mailing address:
  • Phone: 240-945-6121
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code374U00000X
TaxonomyHome Health Aide
License NumberHHA200006168
License Number StateDC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: