Healthcare Provider Details

I. General information

NPI: 1265143283
Provider Name (Legal Business Name): KALU OKORIE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/09/2022
Last Update Date: 09/09/2024
Certification Date: 09/09/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

16416 W DESERT MIRAGE DR
SURPRISE AZ
85388-5491
US

IV. Provider business mailing address

16416 W DESERT MIRAGE DR
SURPRISE AZ
85388-5491
US

V. Phone/Fax

Practice location:
  • Phone: 480-360-1002
  • Fax:
Mailing address:
  • Phone: 480-360-1002
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number284759
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: