Healthcare Provider Details

I. General information

NPI: 1588728422
Provider Name (Legal Business Name): ELIZABETH J BOLAJI CNM, NP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/21/2006
Last Update Date: 10/18/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1177 N PARK AVE
POMONA CA
91768-3028
US

IV. Provider business mailing address

14015 CHARLEMAGNE AVE
BELLFLOWER CA
90706-2331
US

V. Phone/Fax

Practice location:
  • Phone: 909-623-9900
  • Fax: 909-623-1993
Mailing address:
  • Phone: 562-925-8252
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberNP CERTIFICATE 15797
License Number StateCA
# 2
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberNMW 1120
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: