Provider Demographics
NPI:1881247229
Name:OKONKO, CHIEMEZIE
Entity type:Individual
Prefix:
First Name:CHIEMEZIE
Middle Name:
Last Name:OKONKO
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 1:719 STEPNEY ST
Mailing Address - Street 2:
Mailing Address - City:INGLEWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:90302-2530
Mailing Address - Country:US
Mailing Address - Phone:310-925-8412
Mailing Address - Fax:
Practice Address - Street 1:719 STEPNEY ST
Practice Address - Street 2:
Practice Address - City:INGLEWOOD
Practice Address - State:CA
Practice Address - Zip Code:90302-2530
Practice Address - Country:US
Practice Address - Phone:310-925-8412
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-07-23
Last Update Date:2021-07-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014392363LP0808X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health