Healthcare Provider Details

I. General information

NPI: 1104607068
Provider Name (Legal Business Name): MODUPE G. OKHIPO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2023
Last Update Date: 09/10/2026
Certification Date: 09/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

239 CRANSTON ST
PROVIDENCE RI
02907-2406
US

IV. Provider business mailing address

375 ALLENS AVE
PROVIDENCE RI
02905-5010
US

V. Phone/Fax

Practice location:
  • Phone: 401-444-0580
  • Fax: 401-444-0428
Mailing address:
  • Phone: 401-444-0400
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2310139
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAPRN05430
License Number StateRI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: