Healthcare Provider Details

I. General information

NPI: 1821477258
Provider Name (Legal Business Name): ROSELYNE A OGOLA-MWANGALE NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/18/2015
Last Update Date: 09/21/2022
Certification Date: 09/21/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5608 17TH AVE NW STE 1527
SEATTLE WA
98107-5232
US

IV. Provider business mailing address

24463 W 10 MILE RD
SOUTHFIELD MI
48033-2931
US

V. Phone/Fax

Practice location:
  • Phone: 206-612-1216
  • Fax:
Mailing address:
  • Phone: 248-829-9692
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number4704296484
License Number StateMI
# 2
Primary TaxonomyN
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number4704296484
License Number StateMI
# 3
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP61285822
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: