Provider Demographics
NPI:1679762595
Name:LA SAULLE, BROOKE AMBER (NP & CNM)
Entity Type:Individual
Prefix:MISS
First Name:BROOKE
Middle Name:AMBER
Last Name:LA SAULLE
Suffix:
Gender:F
Credentials:NP & CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1950 GREENFIELD AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90025-5712
Mailing Address - Country:US
Mailing Address - Phone:415-218-3981
Mailing Address - Fax:
Practice Address - Street 1:1950 GREENFIELD AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90025-5712
Practice Address - Country:US
Practice Address - Phone:415-218-3981
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-10-16
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANMW1783176B00000X, 367A00000X
CA17578363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No176B00000XOther Service ProvidersMidwife
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
CANMW1783OtherMEDICAL LICENSE