Healthcare Provider Details

I. General information

NPI: 1912439647
Provider Name (Legal Business Name): JOHN OKOLO N.P
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/31/2017
Last Update Date: 08/12/2024
Certification Date: 08/12/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

502 BOX ELDER CT
BONAIRE GA
31005-5401
US

IV. Provider business mailing address

502 BOX ELDER CT
BONAIRE GA
31005-5401
US

V. Phone/Fax

Practice location:
  • Phone: 678-559-8969
  • Fax:
Mailing address:
  • Phone: 678-559-8969
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number4704416472
License Number StateMI
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN217300
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: