Healthcare Provider Details

I. General information

NPI: 1275044851
Provider Name (Legal Business Name): IKECHUKWU HENRY OKOLOCHA FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/23/2017
Last Update Date: 09/11/2023
Certification Date: 09/11/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

783 N DENTON TAP RD STE 150
COPPELL TX
75019-2129
US

IV. Provider business mailing address

783 N DENTON TAP RD STE 150
COPPELL TX
75019-2129
US

V. Phone/Fax

Practice location:
  • Phone: 469-289-2660
  • Fax: 469-324-4230
Mailing address:
  • Phone: 469-289-2660
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP135695
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: