Provider Demographics
NPI:1538823133
Name:OKEYO, IMMACULATE
Entity type:Individual
Prefix:
First Name:IMMACULATE
Middle Name:
Last Name:OKEYO
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 1:7111 BOSQUE BLVD STE 303
Mailing Address - Street 2:
Mailing Address - City:WACO
Mailing Address - State:TX
Mailing Address - Zip Code:76710-4071
Mailing Address - Country:US
Mailing Address - Phone:254-307-3997
Mailing Address - Fax:254-300-9935
Practice Address - Street 1:7111 BOSQUE BLVD STE 303
Practice Address - Street 2:
Practice Address - City:WACO
Practice Address - State:TX
Practice Address - Zip Code:76710-4071
Practice Address - Country:US
Practice Address - Phone:254-307-3997
Practice Address - Fax:254-300-9935
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-29
Last Update Date:2023-03-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX1056692363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health