Provider Demographics
NPI:1831776723
Name:EBONG, DIVINE M
Entity type:Individual
Prefix:
First Name:DIVINE
Middle Name:M
Last Name:EBONG
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 1:6939 GEORGIA AVE NW
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:DC
Mailing Address - Zip Code:20012-2456
Mailing Address - Country:US
Mailing Address - Phone:202-372-6641
Mailing Address - Fax:
Practice Address - Street 1:6939 GEORGIA AVE NW
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20012-2456
Practice Address - Country:US
Practice Address - Phone:202-372-6641
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-26
Last Update Date:2021-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
DCHHA15690Medicaid