Healthcare Provider Details

I. General information

NPI: 1699801100
Provider Name (Legal Business Name): TERESA R MALONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/26/2007
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

23517 MAIN ST STE 103
CARSON CA
90745-5234
US

IV. Provider business mailing address

23034 MISSION DR
CARSON CA
90745-4953
US

V. Phone/Fax

Practice location:
  • Phone: 310-834-5388
  • Fax:
Mailing address:
  • Phone: 310-816-9935
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number463727
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: