Healthcare Provider Details

I. General information

NPI: 1063095503
Provider Name (Legal Business Name): BOLATITO OYERONKE OKOUGBO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/03/2021
Last Update Date: 05/03/2021
Certification Date: 04/30/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

10926 W IVORY LN
AVONDALE AZ
85392-4025
US

IV. Provider business mailing address

10926 W IVORY LN
AVONDALE AZ
85392-4025
US

V. Phone/Fax

Practice location:
  • Phone: 623-977-7644
  • Fax:
Mailing address:
  • Phone: 623-877-7644
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number257217
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: