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General NPI Number Information
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NPI Number | 1003433079
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Entity Type | Organization
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Legal Business Name | DIVINE HEALTHCARE
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Dates
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Enumeration Date | 06/25/2020
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Last Update Date | 11/05/2021
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Provider Practice Location Address
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Address Line | 1778 GRANDE VIEW AVE
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City | SEVERN
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State | MD
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Zip | 21144-3333
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Country | US
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Telephone | 410-551-5849
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Fax | 410-551-0685
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Provider Business Mailing Address
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Address Line | 1778 GRANDE VIEW AVE
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City | SEVERN
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State | MD
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Zip | 21144-3333
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Country | US
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Telephone | 410-551-5849
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Fax | 410-551-0685
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Authorized Official
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Title or Position | PRESIDENT
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Name | ABIMBOLA HILLARD
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Credential | FNP-BC
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Telephone | 240-501-8616
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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