Provider Demographics
NPI:1083151609
Name:MALCOLM, GIAVONNA CAROLENNA (LPN)
Entity type:Individual
Prefix:
First Name:GIAVONNA
Middle Name:CAROLENNA
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:571 EAST 28TH STREET 2ND FLOOR
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11210
Mailing Address - Country:US
Mailing Address - Phone:347-348-8805
Mailing Address - Fax:
Practice Address - Street 1:571 E 28TH ST FL 2
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11210-1433
Practice Address - Country:US
Practice Address - Phone:347-348-8805
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-01-20
Last Update Date:2017-01-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY288193164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse