Provider Demographics
NPI:1457965352
Name:POPOOLA, ROSELINE OMOLOLA (BS)
Entity Type:Individual
Prefix:
First Name:ROSELINE
Middle Name:OMOLOLA
Last Name:POPOOLA
Suffix:
Gender:F
Credentials:BS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:652 FOXTAIL DR
Mailing Address - Street 2:
Mailing Address - City:FLORISSANT
Mailing Address - State:MO
Mailing Address - Zip Code:63034-2035
Mailing Address - Country:US
Mailing Address - Phone:314-583-2694
Mailing Address - Fax:
Practice Address - Street 1:652 FOXTAIL DR
Practice Address - Street 2:
Practice Address - City:FLORISSANT
Practice Address - State:MO
Practice Address - Zip Code:63034-2035
Practice Address - Country:US
Practice Address - Phone:314-583-2694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-09-08
Last Update Date:2020-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO123336376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide