MEDICARE: OKEY ILOEGBUNAM FNP

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	208VP0000X	Pain Medicine Physician	AP10673	AZ
2	363LF0000X	Family Nurse Practitioner	AP10673	AZ
3	363L00000X	Nurse Practitioner	AP10673	AZ

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	MEDICAID ID Found: Get Medicaid Details using Online Medicaid Verification Program

General Provider Information

NPI Number	:	1477072130
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	OKEY ILOEGBUNAM FNP

Provider Business Mailing Address
First Line	:	PO BOX 10966
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86427-0966
Country	:	US
Telephone Number	:	928-788-3333
Fax Number	:	928-788-3555

Provider Business Practice Location Address
First Line	:	1510 E WAGON WHEEL LN STE 110
Second Line	:
City	:	FORT MOHAVE
State	:	AZ
Zip	:	86426-6698
Country	:	US
Telephone Number	:	928-788-3333
Fax Number	:	928-788-3555

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

Provider Enumeration Date	:	09/14/2017
Last Update Date	:	03/17/2018

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Directions to “ OKEY ILOEGBUNAM FNP” Practice Location

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