Provider Demographics
NPI:1629772629
Name:FOMULYAM, DIVINE
Entity Type:Individual
Prefix:
First Name:DIVINE
Middle Name:
Last Name:FOMULYAM
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14912 DOVEHEART LN
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-3079
Mailing Address - Country:US
Mailing Address - Phone:240-548-7667
Mailing Address - Fax:
Practice Address - Street 1:213 L ST SW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20024-3607
Practice Address - Country:US
Practice Address - Phone:240-899-4815
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-03-27
Last Update Date:2023-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant