Healthcare Provider Details

I. General information

NPI: 1538906771
Provider Name (Legal Business Name): GWENETH DELILAH MALMQUIST LE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/15/2024
Last Update Date: 07/15/2024
Certification Date: 07/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 W CALIFORNIA BLVD STE 228
PASADENA CA
91105-3033
US

IV. Provider business mailing address

159 N MARENGO AVE APT 102
PASADENA CA
91101-4505
US

V. Phone/Fax

Practice location:
  • Phone: 909-206-2443
  • Fax:
Mailing address:
  • Phone: 909-257-7085
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code247200000X
TaxonomyOther Technician
License NumberL9928
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: