Healthcare Provider Details

I. General information

NPI: 1699099424
Provider Name (Legal Business Name): PRINCE OKOSUN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/23/2010
Last Update Date: 10/03/2022
Certification Date: 10/03/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6838 W SUNSET BLVD
HOLLYWOOD CA
90028-7008
US

IV. Provider business mailing address

9808 VENICE BLVD SUITE 700
CULVER CITY CA
90232-2732
US

V. Phone/Fax

Practice location:
  • Phone: 323-461-3161
  • Fax: 323-461-5683
Mailing address:
  • Phone: 310-945-3350
  • Fax: 310-840-7023

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number550304
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95017967
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: