Healthcare Provider Details

I. General information

NPI: 1306740550
Provider Name (Legal Business Name): BENICIA MALONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 10/02/2026
Last Update Date: 10/02/2026
Certification Date: 10/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

480 ASHTON CIR
MCDONOUGH GA
30253-8909
US

IV. Provider business mailing address

480 ASHTON CIR
MCDONOUGH GA
30253-8909
US

V. Phone/Fax

Practice location:
  • Phone: 470-330-6888
  • Fax:
Mailing address:
  • Phone: 470-330-6888
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code224Y00000X
TaxonomyClinical Exercise Physiologist
License Number2017943
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: