Healthcare Provider Details

I. General information

NPI: 1164797676
Provider Name (Legal Business Name): UJU DOMITILA OKOLI RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/16/2012
Last Update Date: 03/16/2012
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

85 SAINT JOSEPHS AVE
STATEN ISLAND NY
10302-1115
US

IV. Provider business mailing address

85 SAINT JOSEPHS AVE
STATEN ISLAND NY
10302-1115
US

V. Phone/Fax

Practice location:
  • Phone: 718-420-2115
  • Fax:
Mailing address:
  • Phone: 718-420-2115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number22556519
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: