Provider Demographics
NPI:1437630688
Name:OKELARIN, IMANI
Entity Type:Individual
Prefix:
First Name:IMANI
Middle Name:
Last Name:OKELARIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1077 BROOKDALE AVE
Mailing Address - Street 2:
Mailing Address - City:BAY SHORE
Mailing Address - State:NY
Mailing Address - Zip Code:11706-1813
Mailing Address - Country:US
Mailing Address - Phone:631-741-2435
Mailing Address - Fax:
Practice Address - Street 1:1077 BROOKDALE AVE
Practice Address - Street 2:
Practice Address - City:BAY SHORE
Practice Address - State:NY
Practice Address - Zip Code:11706-1813
Practice Address - Country:US
Practice Address - Phone:631-741-2435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-26
Last Update Date:2018-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY332591164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY914716278OtherDRIVERS LICENSE