Provider Demographics
NPI:1700443157
Name:OKONKWO, IMMACULATA ADAUGO
Entity Type:Individual
Prefix:
First Name:IMMACULATA
Middle Name:ADAUGO
Last Name:OKONKWO
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 1:14116 BUCK HILL CT
Mailing Address - Street 2:
Mailing Address - City:BURTONSVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20866-2073
Mailing Address - Country:US
Mailing Address - Phone:202-330-8160
Mailing Address - Fax:
Practice Address - Street 1:14116 BUCK HILL CT
Practice Address - Street 2:
Practice Address - City:BURTONSVILLE
Practice Address - State:MD
Practice Address - Zip Code:20866-2073
Practice Address - Country:US
Practice Address - Phone:202-330-8160
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-05-21
Last Update Date:2019-05-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN1015902363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty