Provider Demographics
NPI:1710299862
Name:OKIMOTO, SUMMER JOY (CNM)
Entity Type:Individual
Prefix:
First Name:SUMMER
Middle Name:JOY
Last Name:OKIMOTO
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:SUMMER
Other - Middle Name:JOY
Other - Last Name:LATTA
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CNM, DNP
Mailing Address - Street 1:360 DOGWOOD TRL SE
Mailing Address - Street 2:
Mailing Address - City:MARIETTA
Mailing Address - State:GA
Mailing Address - Zip Code:30067-4653
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:360 DOGWOOD TRL SE
Practice Address - Street 2:
Practice Address - City:MARIETTA
Practice Address - State:GA
Practice Address - Zip Code:30067-4653
Practice Address - Country:US
Practice Address - Phone:817-808-3379
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2010-07-06
Last Update Date:2023-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP119151367A00000X
CO0990974367A00000X
GARN315907367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX217492201Medicaid
TX828N92OtherBCBS
TX217492201Medicaid