Provider Demographics
NPI:1568964104
Name:OKULLO, TARA LEA (AGNP-C)
Entity Type:Individual
Prefix:
First Name:TARA
Middle Name:LEA
Last Name:OKULLO
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7 OWLS COVE PL
Mailing Address - Street 2:
Mailing Address - City:THE WOODLANDS
Mailing Address - State:TX
Mailing Address - Zip Code:77382-1109
Mailing Address - Country:US
Mailing Address - Phone:619-504-0496
Mailing Address - Fax:
Practice Address - Street 1:1480 KATY FLEWELLEN RD
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-6662
Practice Address - Country:US
Practice Address - Phone:281-392-4338
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2018-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136830363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty