Provider Demographics
NPI:1043992365
Name:OKULOV, VASILY (RN)
Entity Type:Individual
Prefix:
First Name:VASILY
Middle Name:
Last Name:OKULOV
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:13808 TEMPLE ST
Mailing Address - Street 2:
Mailing Address - City:POWAY
Mailing Address - State:CA
Mailing Address - Zip Code:92064-3450
Mailing Address - Country:US
Mailing Address - Phone:925-451-0485
Mailing Address - Fax:
Practice Address - Street 1:5055 RUFFIN RD
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92123-1617
Practice Address - Country:US
Practice Address - Phone:619-246-0371
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-04
Last Update Date:2023-08-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA552041163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse