Healthcare Provider Details

I. General information

NPI: 1598224156
Provider Name (Legal Business Name): IFEOMA OKONKWO PNP-PC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: IFY OKONKWO

II. Dates (important events)

Enumeration Date: 03/13/2019
Last Update Date: 03/14/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5200 HARRY HINES BLVD
DALLAS TX
75235-7709
US

IV. Provider business mailing address

10215 SUNRIDGE TRL
DALLAS TX
75243-2546
US

V. Phone/Fax

Practice location:
  • Phone: 214-590-0153
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberAP140788
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: