MEDICARE: DIVINE FAMILY PRACTICE AND URGENT CARE, PLLC

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	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1548881279
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	DIVINE FAMILY PRACTICE AND URGENT CARE, PLLC

Provider Business Mailing Address
First Line	:	3616 CAPE CENTER DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4456
Country	:	US
Telephone Number	:	910-900-8294
Fax Number	:	910-900-8280

Provider Business Practice Location Address
First Line	:	3616 CAPE CENTER DR
Second Line	:
City	:	FAYETTEVILLE
State	:	NC
Zip	:	28304-4456
Country	:	US
Telephone Number	:	910-900-8294
Fax Number	:	910-900-8280

Authorized Official
Title or Position	:	DNP, FNP-BC
Name	:	ABIMBOLA A OGUNLEYE-KOLAWOLE
Credential	:
Telephone Number	:	910-900-8294

Provider Enumeration Date	:	05/05/2020
Last Update Date	:	08/30/2023

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