Provider Demographics
NPI:1699801100
Name:MALONE, TERESA R
Entity type:Individual
Prefix:
First Name:TERESA
Middle Name:R
Last Name:MALONE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:23034 MISSION DR
Mailing Address - Street 2:
Mailing Address - City:CARSON
Mailing Address - State:CA
Mailing Address - Zip Code:90745-4953
Mailing Address - Country:US
Mailing Address - Phone:310-816-9935
Mailing Address - Fax:
Practice Address - Street 1:23517 MAIN ST STE 103
Practice Address - Street 2:
Practice Address - City:CARSON
Practice Address - State:CA
Practice Address - Zip Code:90745-5234
Practice Address - Country:US
Practice Address - Phone:310-834-5388
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-02-26
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA463727163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA12886OtherNURSING CERTIFICATE
CA463727OtherNURSE PRACTITIONER