Provider Demographics
NPI:1255940946
Name:OKEHIE, CHISOM UDOKA
Entity type:Individual
Prefix:
First Name:CHISOM
Middle Name:UDOKA
Last Name:OKEHIE
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 1:3186 CRESTON PARK CT
Mailing Address - Street 2:
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8959
Mailing Address - Country:US
Mailing Address - Phone:678-468-2580
Mailing Address - Fax:404-601-9779
Practice Address - Street 1:3186 CRESTON PARK CT
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8959
Practice Address - Country:US
Practice Address - Phone:678-468-2580
Practice Address - Fax:404-601-9779
Is Sole Proprietor?:No
Enumeration Date:2020-07-28
Last Update Date:2020-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAPHCP010715374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide