Healthcare Provider Details

I. General information

NPI: 1487404042
Provider Name (Legal Business Name): KOMI AGBEKO DZOKPE PMHNP-BC
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/26/2024
Last Update Date: 11/14/2024
Certification Date: 11/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

509 N BRIGHTLEAF BLVD
SMITHFIELD NC
27577-4407
US

IV. Provider business mailing address

4817 TOMMANS TRL
RALEIGH NC
27616-0760
US

V. Phone/Fax

Practice location:
  • Phone: 919-938-7558
  • Fax: 919-934-7554
Mailing address:
  • Phone: 919-986-5116
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number2023166604
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: