Provider Demographics
NPI:1851041461
Name:FOLEFAC, ACHIANU DIVINE
Entity Type:Individual
Prefix:
First Name:ACHIANU
Middle Name:DIVINE
Last Name:FOLEFAC
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 1:14410 STEPPING STONE WAY
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-1937
Mailing Address - Country:US
Mailing Address - Phone:240-355-9619
Mailing Address - Fax:
Practice Address - Street 1:9470 ANNAPOLIS RD
Practice Address - Street 2:
Practice Address - City:LANHAM
Practice Address - State:MD
Practice Address - Zip Code:20706-3025
Practice Address - Country:US
Practice Address - Phone:202-499-4300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-03-25
Last Update Date:2022-03-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR212231163WP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health