Healthcare Provider Details

I. General information

NPI: 1750048708
Provider Name (Legal Business Name): IVY ROSE MALIT FNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/24/2021
Last Update Date: 11/25/2021
Certification Date: 11/25/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3330 LOMITA BLVD
TORRANCE CA
90505-5002
US

IV. Provider business mailing address

3330 LOMITA BLVD
TORRANCE CA
90505-5002
US

V. Phone/Fax

Practice location:
  • Phone: 310-325-9110
  • Fax:
Mailing address:
  • Phone: 310-325-9110
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95013533
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: