Provider Demographics
NPI:1699099424
Name:OKOSUN, PRINCE
Entity type:Individual
Prefix:
First Name:PRINCE
Middle Name:
Last Name:OKOSUN
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9808 VENICE BLVD
Mailing Address - Street 2:SUITE 700
Mailing Address - City:CULVER CITY
Mailing Address - State:CA
Mailing Address - Zip Code:90232-2732
Mailing Address - Country:US
Mailing Address - Phone:310-945-3350
Mailing Address - Fax:310-840-7023
Practice Address - Street 1:6838 W SUNSET BLVD
Practice Address - Street 2:
Practice Address - City:HOLLYWOOD
Practice Address - State:CA
Practice Address - Zip Code:90028-7008
Practice Address - Country:US
Practice Address - Phone:323-461-3161
Practice Address - Fax:323-461-5683
Is Sole Proprietor?:Yes
Enumeration Date:2010-03-23
Last Update Date:2022-10-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA550304163WP0808X
CA95017967363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163WP0808XNursing Service ProvidersRegistered NursePsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
$$$$$$$$$OtherSSN