Healthcare Provider Details

I. General information

NPI: 1457670630
Provider Name (Legal Business Name): MISS MALESSIA IYABO FORREST
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/27/2010
Last Update Date: 05/27/2010
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

521 FREMONT DR
PASADENA CA
91103-3215
US

IV. Provider business mailing address

521 FREMONT DR
PASADENA CA
91103-3215
US

V. Phone/Fax

Practice location:
  • Phone: 310-728-9587
  • Fax:
Mailing address:
  • Phone: 310-728-9587
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code174H00000X
TaxonomyHealth Educator
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: