Provider Demographics
NPI:1861280752
Name:OKPEBHOLO, HEIDI
Entity type:Individual
Prefix:
First Name:HEIDI
Middle Name:
Last Name:OKPEBHOLO
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 COLONIAL CT
Mailing Address - Street 2:
Mailing Address - City:HAINESPORT
Mailing Address - State:NJ
Mailing Address - Zip Code:08036-2636
Mailing Address - Country:US
Mailing Address - Phone:732-589-5784
Mailing Address - Fax:
Practice Address - Street 1:1 COLONIAL CT
Practice Address - Street 2:
Practice Address - City:HAINESPORT
Practice Address - State:NJ
Practice Address - Zip Code:08036-2636
Practice Address - Country:US
Practice Address - Phone:732-589-5784
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-04-29
Last Update Date:2025-04-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ15295900363LF0000X
OHAPRN.CNP.0038138363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily