Provider Demographics
NPI:1730753989
Name:ROSANWO, MOBOLAJI (DNP CRNP PHMNP-BC)
Entity type:Individual
Prefix:
First Name:MOBOLAJI
Middle Name:
Last Name:ROSANWO
Suffix:
Gender:F
Credentials:DNP CRNP PHMNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:418 BROADWAY STE N
Mailing Address - Street 2:
Mailing Address - City:ALBANY
Mailing Address - State:NY
Mailing Address - Zip Code:12207-2922
Mailing Address - Country:US
Mailing Address - Phone:443-858-1968
Mailing Address - Fax:
Practice Address - Street 1:418 BROADWAY STE N
Practice Address - Street 2:
Practice Address - City:ALBANY
Practice Address - State:NY
Practice Address - Zip Code:12207-2922
Practice Address - Country:US
Practice Address - Phone:443-858-1968
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-05-13
Last Update Date:2024-05-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD223563363LP0808X
NY403963363LP0808X
WAAP61358864363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health