Provider Demographics
NPI:1215325535
Name:OKONOFUA, MODUPE MARY (NP-C)
Entity type:Individual
Prefix:
First Name:MODUPE
Middle Name:MARY
Last Name:OKONOFUA
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7244 BOREAL DR
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80915-3766
Mailing Address - Country:US
Mailing Address - Phone:817-805-9137
Mailing Address - Fax:
Practice Address - Street 1:2135 SOUTHGATE RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80906-2693
Practice Address - Country:US
Practice Address - Phone:719-633-4114
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-01-09
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO0001591-C-NP363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health