Provider Demographics
NPI:1497021943
Name:DIVINE, SALLY (HHA)
Entity Type:Individual
Prefix:
First Name:SALLY
Middle Name:
Last Name:DIVINE
Suffix:
Gender:F
Credentials:HHA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7810 CONTEE RD
Mailing Address - Street 2:#212
Mailing Address - City:LAUREL
Mailing Address - State:MD
Mailing Address - Zip Code:20707-9203
Mailing Address - Country:US
Mailing Address - Phone:202-545-0935
Mailing Address - Fax:
Practice Address - Street 1:7810 CONTEE RD
Practice Address - Street 2:#212
Practice Address - City:LAUREL
Practice Address - State:MD
Practice Address - Zip Code:20707-9203
Practice Address - Country:US
Practice Address - Phone:202-545-0935
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-03-29
Last Update Date:2012-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide