Provider Demographics
NPI:1871925222
Name:OMOLOLU, ROSCHELLE RENEE (CNM)
Entity type:Individual
Prefix:MS
First Name:ROSCHELLE
Middle Name:RENEE
Last Name:OMOLOLU
Suffix:
Gender:F
Credentials:CNM
Other - Prefix:
Other - First Name:ROSCHELLE
Other - Middle Name:RENEE
Other - Last Name:BOYD
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:CNM
Mailing Address - Street 1:1200 N STATE ST
Mailing Address - Street 2:INPATIENT TOWER - C3F102
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90089-1001
Mailing Address - Country:US
Mailing Address - Phone:323-409-1416
Mailing Address - Fax:
Practice Address - Street 1:1200 N STATE ST
Practice Address - Street 2:INPATIENT TOWER - C3F102
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-1001
Practice Address - Country:US
Practice Address - Phone:323-409-1416
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-08-07
Last Update Date:2023-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA23401363LW0102X
CA2060367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health