MEDICARE: GREEN MINDS MATTER LLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1194325308
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	GREEN MINDS MATTER LLC

Provider Business Mailing Address
First Line	:	4940 CATTLE LN
Second Line	:
City	:	EL PASO
State	:	TX
Zip	:	79934-2835
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5805 MCNUTT RD
Second Line	:
City	:	SANTA TERESA
State	:	NM
Zip	:	88008-8001
Country	:	US
Telephone Number	:	469-569-8665
Fax Number	:

Authorized Official
Title or Position	:	FOUNDER
Name	:	DR. IRENE OKORONKWO
Credential	:	DNP
Telephone Number	:	469-569-8665

Provider Enumeration Date	:	10/27/2020
Last Update Date	:	10/27/2020

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