Healthcare Provider Details

I. General information

NPI: 1336684117
Provider Name (Legal Business Name): PAMELA MOKOKO
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 01/03/2017
Last Update Date: 01/03/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

165 WILLOW OAK DR
RICHMOND HILL GA
31324-4069
US

IV. Provider business mailing address

165 WILLOW OAK DR
RICHMOND HILL GA
31324-4069
US

V. Phone/Fax

Practice location:
  • Phone: 912-224-1156
  • Fax:
Mailing address:
  • Phone: 912-224-1156
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code261QM0801X
TaxonomyMental Health Clinic/Center (Including Community Mental Health Center)
License Number
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code261QP2300X
TaxonomyPrimary Care Clinic/Center
License Number
License Number StateGA

VIII. Authorized Official

Name: MRS. PAMELA E MOKOKO
Title or Position: PRESIDENT
Credential: APRN, FNP, PMHNP
Phone: 912-224-1156