Provider Demographics
NPI:1700257441
Name:OKEBALAMA, KODILIM ANNE MUKOSO (FNP-C)
Entity type:Individual
Prefix:MRS
First Name:KODILIM
Middle Name:ANNE MUKOSO
Last Name:OKEBALAMA
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:77 PRESIDENTIAL DR
Mailing Address - Street 2:#2
Mailing Address - City:QUINCY
Mailing Address - State:MA
Mailing Address - Zip Code:02169-8847
Mailing Address - Country:US
Mailing Address - Phone:781-308-8028
Mailing Address - Fax:
Practice Address - Street 1:626 SOUTHERN ARTERY
Practice Address - Street 2:MINUTECLINIC
Practice Address - City:QUINCY
Practice Address - State:MA
Practice Address - Zip Code:02169-5648
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-10-07
Last Update Date:2015-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2291065363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily