Provider Demographics
NPI:1588075865
Name:ISIDIENU, OKAGBUO CONSTANTINE (LVN)
Entity type:Individual
Prefix:MR
First Name:OKAGBUO
Middle Name:CONSTANTINE
Last Name:ISIDIENU
Suffix:
Gender:M
Credentials:LVN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:8810 RIO SAN DIEGO DR
Mailing Address - Street 2:2ND FLOOR
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92108-1698
Mailing Address - Country:US
Mailing Address - Phone:858-552-8585
Mailing Address - Fax:
Practice Address - Street 1:8810 RIO SAN DIEGO DR
Practice Address - Street 2:2ND FLOOR
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92108-1698
Practice Address - Country:US
Practice Address - Phone:858-552-8585
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-05-08
Last Update Date:2014-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAVN277859164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse