Provider Demographics
NPI:1669197208
Name:FUBE DIVINE, NGUFOR (CRNP-PMH)
Entity type:Individual
Prefix:DR
First Name:NGUFOR
Middle Name:
Last Name:FUBE DIVINE
Suffix:
Gender:M
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8210 JEREMIAH LN
Mailing Address - Street 2:
Mailing Address - City:COLUMBIA
Mailing Address - State:MD
Mailing Address - Zip Code:21044-4165
Mailing Address - Country:US
Mailing Address - Phone:240-423-8757
Mailing Address - Fax:301-368-6675
Practice Address - Street 1:8210 JEREMIAH LN
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044-4165
Practice Address - Country:US
Practice Address - Phone:240-423-8757
Practice Address - Fax:301-368-6675
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-06
Last Update Date:2024-07-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCNP1059918363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health