Provider Demographics
NPI:1548881279
Name:DIVINE FAMILY PRACTICE AND URGENT CARE, PLLC
Entity type:Organization
Organization Name:DIVINE FAMILY PRACTICE AND URGENT CARE, PLLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:DNP, FNP-BC
Authorized Official - Prefix:
Authorized Official - First Name:ABIMBOLA
Authorized Official - Middle Name:A
Authorized Official - Last Name:OGUNLEYE-KOLAWOLE
Authorized Official - Suffix:
Authorized Official - Credentials:
Authorized Official - Phone:910-900-8294
Mailing Address - Street 1:3616 CAPE CENTER DR
Mailing Address - Street 2:
Mailing Address - City:FAYETTEVILLE
Mailing Address - State:NC
Mailing Address - Zip Code:28304-4456
Mailing Address - Country:US
Mailing Address - Phone:910-900-8294
Mailing Address - Fax:910-900-8280
Practice Address - Street 1:3616 CAPE CENTER DR
Practice Address - Street 2:
Practice Address - City:FAYETTEVILLE
Practice Address - State:NC
Practice Address - Zip Code:28304-4456
Practice Address - Country:US
Practice Address - Phone:910-900-8294
Practice Address - Fax:910-900-8280
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2020-05-05
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary CareGroup - Multi-Specialty