Healthcare Provider Details

I. General information

NPI: 1831814342
Provider Name (Legal Business Name): CHISOM C OKPARA
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/06/2022
Last Update Date: 03/21/2023
Certification Date: 03/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

30 SANDSTONE CIR
JACKSON TN
38305-2073
US

IV. Provider business mailing address

30 SANDSTONE CIR
JACKSON TN
38305-2073
US

V. Phone/Fax

Practice location:
  • Phone: 731-240-1695
  • Fax:
Mailing address:
  • Phone: 731-240-1695
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WG0000X
TaxonomyGeneral Practice Registered Nurse
License Number682845
License Number StateTX
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1096592
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: