Healthcare Provider Details

I. General information

NPI: 1659995595
Provider Name (Legal Business Name): PAUL OKORONKWO
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/06/2020
Last Update Date: 05/09/2024
Certification Date: 05/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7075 W BELL RD STE A-1
GLENDALE AZ
85308-8546
US

IV. Provider business mailing address

7655 W MARY JANE LN
PEORIA AZ
85382-3842
US

V. Phone/Fax

Practice location:
  • Phone: 602-348-1338
  • Fax: 602-297-6566
Mailing address:
  • Phone: 602-348-1338
  • Fax: 602-297-6566

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number241990
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: