Provider Demographics
NPI:1609422534
Name:OKOROM, CHARLES (CRNP-PMH)
Entity Type:Individual
Prefix:
First Name:CHARLES
Middle Name:
Last Name:OKOROM
Suffix:
Gender:M
Credentials:CRNP-PMH
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9605 TOUCAN DR
Mailing Address - Street 2:
Mailing Address - City:UPPER MARLBORO
Mailing Address - State:MD
Mailing Address - Zip Code:20772-4780
Mailing Address - Country:US
Mailing Address - Phone:443-341-7368
Mailing Address - Fax:
Practice Address - Street 1:9605 TOUCAN DR
Practice Address - Street 2:
Practice Address - City:UPPER MARLBORO
Practice Address - State:MD
Practice Address - Zip Code:20772-4780
Practice Address - Country:US
Practice Address - Phone:443-341-7368
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-08-15
Last Update Date:2019-08-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR200643363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty