MEDICARE: MODUPE MARY OKONOFUA PMHNP-BC, FNP-C

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	0001591-C-NP	CO
2	363LF0000X	Family Nurse Practitioner	0001591-C-NP	CO

General Provider Information

NPI Number	:	1215325535
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MODUPE MARY OKONOFUA PMHNP-BC, FNP-C

Provider Business Mailing Address
First Line	:	3585 VAN TEYLINGEN DR STE D
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4872
Country	:	US
Telephone Number	:	719-413-5005
Fax Number	:	719-413-5006

Provider Business Practice Location Address
First Line	:	3585 VAN TEYLINGEN DR STE D
Second Line	:
City	:	COLORADO SPRINGS
State	:	CO
Zip	:	80917-4872
Country	:	US
Telephone Number	:	719-413-5005
Fax Number	:	719-413-5006

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/09/2015
Last Update Date	:	06/13/2025

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