Healthcare Provider Details

I. General information

NPI: 1386579274
Provider Name (Legal Business Name): MS. NISSI OKOLOSI
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/15/2026
Last Update Date: 07/10/2026
Certification Date: 07/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

31 RANCHO CAMINO DR, FLOOR 2, POMONA, CA 91766
POMONA CA
91766
US

IV. Provider business mailing address

3380 BLISS CT
RIVERSIDE CA
92503-5252
US

V. Phone/Fax

Practice location:
  • Phone: 951-452-9266
  • Fax:
Mailing address:
  • Phone: 951-452-9266
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code106S00000X
TaxonomyBehavior Technician
License Number
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: