Provider Demographics
NPI:1912512864
Name:DIEJOMAOH, OKIEMUTE
Entity Type:Individual
Prefix:
First Name:OKIEMUTE
Middle Name:
Last Name:DIEJOMAOH
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 1:8134 NAZARETH DR
Mailing Address - Street 2:
Mailing Address - City:CORPUS CHRISTI
Mailing Address - State:TX
Mailing Address - Zip Code:78413-6008
Mailing Address - Country:US
Mailing Address - Phone:361-288-2075
Mailing Address - Fax:
Practice Address - Street 1:6300 OCEAN DR
Practice Address - Street 2:TAMUCC - HEALTH CENTER
Practice Address - City:CORPUS CHRISTI
Practice Address - State:TX
Practice Address - Zip Code:78412-5503
Practice Address - Country:US
Practice Address - Phone:361-825-2601
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-08
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1011825363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily