Provider Demographics
NPI:1013208271
Name:OKOTAH, WILBERFORCE ERIC (LPN)
Entity Type:Individual
Prefix:MR
First Name:WILBERFORCE
Middle Name:ERIC
Last Name:OKOTAH
Suffix:
Gender:M
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7928 WAGGONER TRACE DRIVE
Mailing Address - Street 2:
Mailing Address - City:BLACKLICK
Mailing Address - State:OH
Mailing Address - Zip Code:43004
Mailing Address - Country:US
Mailing Address - Phone:614-891-4348
Mailing Address - Fax:
Practice Address - Street 1:7928 WAGGONER TRACE DRIVE
Practice Address - Street 2:
Practice Address - City:BLACKLICK
Practice Address - State:OH
Practice Address - Zip Code:43004
Practice Address - Country:US
Practice Address - Phone:614-891-4348
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-04-22
Last Update Date:2011-04-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHPN124168164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse