Healthcare Provider Details

I. General information

NPI: 1851860282
Provider Name (Legal Business Name): CHRISTOPHER ROBERT MALLONEE
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/14/2018
Last Update Date: 11/14/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1125 MONTANA DR
CONWAY AR
72034-3396
US

IV. Provider business mailing address

1125 MONTANA DR
CONWAY AR
72034-3396
US

V. Phone/Fax

Practice location:
  • Phone: 760-819-2650
  • Fax:
Mailing address:
  • Phone: 760-819-2650
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WE0003X
TaxonomyEmergency Registered Nurse
License NumberR102152
License Number StateAR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: