Healthcare Provider Details

I. General information

NPI: 1215325535
Provider Name (Legal Business Name): MODUPE MARY OKONOFUA PMHNP-BC, FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/09/2015
Last Update Date: 06/13/2025
Certification Date: 06/13/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3585 VAN TEYLINGEN DR STE D
COLORADO SPRINGS CO
80917-4872
US

IV. Provider business mailing address

3585 VAN TEYLINGEN DR STE D
COLORADO SPRINGS CO
80917-4872
US

V. Phone/Fax

Practice location:
  • Phone: 719-413-5005
  • Fax: 719-413-5006
Mailing address:
  • Phone: 719-413-5005
  • Fax: 719-413-5006

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number0001591-C-NP
License Number StateCO
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number0001591-C-NP
License Number StateCO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: