Healthcare Provider Details

I. General information

NPI: 1518531599
Provider Name (Legal Business Name): OMOABHIENA JOSEPH OKODUWA RN
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/14/2021
Last Update Date: 05/14/2021
Certification Date: 05/14/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

915 N GRAND BLVD
SAINT LOUIS MO
63106-1621
US

IV. Provider business mailing address

709 BIDDLE ST APT F
SAINT LOUIS MO
63106-4630
US

V. Phone/Fax

Practice location:
  • Phone: 314-652-4100
  • Fax:
Mailing address:
  • Phone: 443-470-2850
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number2020024609
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: