Provider Demographics
NPI:1962219642
Name:DEVINE FAMILY CARE PRACTICE LLC
Entity type:Organization
Organization Name:DEVINE FAMILY CARE PRACTICE LLC
Other - Org Name:<UNAVAIL>
Other - Org Type:
Authorized Official - Title/Position:CHIEF MEDICAL OFFICER
Authorized Official - Prefix:
Authorized Official - First Name:STELLA
Authorized Official - Middle Name:EBERE
Authorized Official - Last Name:MBAH
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, CRNP, FNP-BC
Authorized Official - Phone:443-200-5338
Mailing Address - Street 1:8890 MCDONOGH RD STE 211
Mailing Address - Street 2:
Mailing Address - City:OWINGS MILLS
Mailing Address - State:MD
Mailing Address - Zip Code:21117-5397
Mailing Address - Country:US
Mailing Address - Phone:410-963-9577
Mailing Address - Fax:
Practice Address - Street 1:8890 MCDONOGH RD STE 211
Practice Address - Street 2:
Practice Address - City:OWINGS MILLS
Practice Address - State:MD
Practice Address - Zip Code:21117-5397
Practice Address - Country:US
Practice Address - Phone:410-963-9577
Practice Address - Fax:
EIN:<UNAVAIL>
Is Organization Subpart?:Yes
Parent Organization LBN:DEVINE FAMILY CARE PRACTICE LLC
Parent Organization TIN:<UNAVAIL>
Enumeration Date:2024-12-16
Last Update Date:2024-12-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty