Healthcare Provider Details

I. General information

NPI: 1437899689
Provider Name (Legal Business Name): OGHENERO LUCKY OLOMUKORO PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/29/2022
Last Update Date: 10/12/2022
Certification Date: 10/12/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4 MEMORIAL DR STE 210
ALTON IL
62002-6704
US

IV. Provider business mailing address

4 MEMORIAL DR STE 210
ALTON IL
62002-6704
US

V. Phone/Fax

Practice location:
  • Phone: 618-465-8829
  • Fax: 618-465-5499
Mailing address:
  • Phone: 618-465-8829
  • Fax: 618-465-5499

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number209025704
License Number StateIL

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: