Provider Demographics
NPI:1194550582
Name:MALONE, LIESL EVA
Entity type:Individual
Prefix:
First Name:LIESL
Middle Name:EVA
Last Name:MALONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:LIESL
Other - Middle Name:EVA
Other - Last Name:MALONE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:
Mailing Address - Street 1:415 OCEAN CREEK DR APT 2149
Mailing Address - Street 2:
Mailing Address - City:MYRTLE BEACH
Mailing Address - State:SC
Mailing Address - Zip Code:29572-5785
Mailing Address - Country:US
Mailing Address - Phone:603-531-1770
Mailing Address - Fax:
Practice Address - Street 1:415 OCEAN CREEK DR APT 2149
Practice Address - Street 2:
Practice Address - City:MYRTLE BEACH
Practice Address - State:SC
Practice Address - Zip Code:29572-5785
Practice Address - Country:US
Practice Address - Phone:603-531-1770
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-09-04
Last Update Date:2024-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC347C00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes347C00000XTransportation ServicesPrivate Vehicle