Healthcare Provider Details

I. General information

NPI: 1396521167
Provider Name (Legal Business Name): IFEOMA VIVIAN OKONKWO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/06/2023
Last Update Date: 09/06/2023
Certification Date: 09/06/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4017 MINNESOTA AVE NE
WASHINGTON DC
20019-3541
US

IV. Provider business mailing address

3809 COOPER LN
HYATTSVILLE MD
20784-2452
US

V. Phone/Fax

Practice location:
  • Phone: 202-388-9202
  • Fax:
Mailing address:
  • Phone: 678-394-6790
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number
License Number State

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: