Healthcare Provider Details

I. General information

NPI: 1699594457
Provider Name (Legal Business Name): IVIAN C OKALA RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IVIAN C OKORODUDU RN

II. Dates (important events)

Enumeration Date: 10/08/2024
Last Update Date: 10/08/2024
Certification Date: 10/08/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13320 COUNTRY WALK CT
VAN BUREN TOWNSHIP MI
48111-2368
US

IV. Provider business mailing address

13320 COUNTRY WALK CT
VAN BUREN TOWNSHIP MI
48111-2368
US

V. Phone/Fax

Practice location:
  • Phone: 734-383-0740
  • Fax:
Mailing address:
  • Phone: 734-383-0740
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0809X
TaxonomyAdult Psychiatric/Mental Health Registered Nurse
License Number4704383676
License Number StateMI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: