Healthcare Provider Details

I. General information

NPI: 1912698804
Provider Name (Legal Business Name): MOROMOKE OLOWOOKERE
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/19/2023
Last Update Date: 09/26/2025
Certification Date: 09/26/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19327 BROADACRES AVE
CARSON CA
90746-2707
US

IV. Provider business mailing address

19327 BROADACRES AVE
CARSON CA
90746-2707
US

V. Phone/Fax

Practice location:
  • Phone: 310-706-7113
  • Fax:
Mailing address:
  • Phone: 310-706-7113
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number95036450
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: