Provider Demographics
NPI:1912439647
Name:OKOLO, JOHN (NP)
Entity Type:Individual
Prefix:
First Name:JOHN
Middle Name:
Last Name:OKOLO
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3871 NORTHSIDE DR APT J6
Mailing Address - Street 2:
Mailing Address - City:MACON
Mailing Address - State:GA
Mailing Address - Zip Code:31210-2421
Mailing Address - Country:US
Mailing Address - Phone:678-559-8969
Mailing Address - Fax:
Practice Address - Street 1:3871 NORTHSIDE DR APT J6
Practice Address - Street 2:
Practice Address - City:MACON
Practice Address - State:GA
Practice Address - Zip Code:31210-2421
Practice Address - Country:US
Practice Address - Phone:678-559-8969
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-31
Last Update Date:2018-04-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN217300363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology