Basic Information
Provider Information
NPI: 1003007113
EntityType: 1
ReplacementNPI:  
OrganizationName:  
LastName: ESSEM
FirstName: DIVINE
MiddleName:  
NamePrefix:  
NameSuffix:  
Credential: LPN
OtherOrganizationName:  
OtherOrganizationType:  
OtherLastName:  
OtherFirstName:  
OtherMiddleName:  
OtherNamePrefix:  
OtherNameSuffix:  
OtherCredential:  
OtherLastNameType:  
Mailing Information
Address1: 11310 EVANS TRL
Address2: APT 102
City: BELTSVILLE
State: MD
PostalCode: 207053007
CountryCode: US
TelephoneNumber:  
FaxNumber:  
Practice Location
Address1: 2250 HICKORY RD
Address2: SUITE 240
City: PLYMOUTH MEETING
State: PA
PostalCode: 194621047
CountryCode: US
TelephoneNumber: 6108341122
FaxNumber:  
Other Information
ProviderEnumerationDate: 08/05/2007
LastUpdateDate: 08/05/2007
NPIDeactivationReasonCode:  
NPIDeactivationDate:  
NPIReactivationDate:  
ProviderGenderCode: F
AuthorizedOfficialLastName:  
AuthorizedOfficialFirstName:  
AuthorizedOfficialMiddleName:  
AuthorizedOfficialTitleorPosition:  
AuthorizedOfficialTelephone:  
IsSoleProprietor: Y
IsOrganizationSubpart:  
ParentOrganizationLBN:  
AuthorizedOfficialNamePrefix:  
AuthorizedOfficialNameSuffix:  
AuthorizedOfficialCredential:  
NPICertificationDate:  

Taxonomy Information
TaxonomyLicenseStateSwitchTaxonomyGroupTaxonomyTypeTaxonomyClassSubSpecialty
164W00000XLP40279MDY Nursing Service ProvidersLicensed Practical Nurse 

No ID Information.


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