Healthcare Provider Details

I. General information

NPI: 1255878211
Provider Name (Legal Business Name): MRS. ISIOMA OKONKWO
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/27/2017
Last Update Date: 01/27/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

260 WINDING RD
ISELIN NJ
08830-2137
US

IV. Provider business mailing address

260 WINDING RD
ISELIN NJ
08830-2137
US

V. Phone/Fax

Practice location:
  • Phone: 678-598-0840
  • Fax: 678-653-8467
Mailing address:
  • Phone: 678-598-0840
  • Fax: 678-653-8467

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code171M00000X
TaxonomyCase Manager/Care Coordinator
License Number045077557
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: