Provider Demographics
NPI:1568964104
Name:OKULLO, TARA LEA (AGNP-C)
Entity type:Individual
Prefix:
First Name:TARA
Middle Name:LEA
Last Name:OKULLO
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:24285 KATY FWY STE 300
Mailing Address - Street 2:
Mailing Address - City:KATY
Mailing Address - State:TX
Mailing Address - Zip Code:77494-1128
Mailing Address - Country:US
Mailing Address - Phone:346-387-7171
Mailing Address - Fax:
Practice Address - Street 1:24285 KATY FWY STE 300
Practice Address - Street 2:
Practice Address - City:KATY
Practice Address - State:TX
Practice Address - Zip Code:77494-1128
Practice Address - Country:US
Practice Address - Phone:346-387-7171
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-02-28
Last Update Date:2024-06-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP136830363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty