MEDICARE: DIVINE HORIZON PMHNP SERVICES, LLC

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1154272714
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE HORIZON PMHNP SERVICES, LLC

Provider Business Mailing Address
First Line	:	5215 N IRONWOOD RD
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-4915
Country	:	US
Telephone Number	:	414-791-9795
Fax Number	:	414-206-2511

Provider Business Practice Location Address
First Line	:	5215 N IRONWOOD RD
Second Line	:
City	:	GLENDALE
State	:	WI
Zip	:	53217-4915
Country	:	US
Telephone Number	:	414-791-9795
Fax Number	:	414-206-2511

Authorized Official
Title or Position	:	PSYCHIATRIC MENTAL HEALTH NP
Name	:	FLORA AGYEI
Credential	:	DNP, PMHNP-BC
Telephone Number	:	414-791-9795

Provider Enumeration Date	:	02/09/2026
Last Update Date	:	02/09/2026

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