Healthcare Provider Details

I. General information

NPI: 1659929487
Provider Name (Legal Business Name): MALAMA MEDICAL
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/26/2019
Last Update Date: 02/01/2021
Certification Date: 02/01/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4604 YORK RD
BALTIMORE MD
21212-4726
US

IV. Provider business mailing address

34 YORK CT
BALTIMORE MD
21218-1248
US

V. Phone/Fax

Practice location:
  • Phone: 443-802-5130
  • Fax:
Mailing address:
  • Phone: 443-802-5130
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: KIMELA JEAN FERGUSON
Title or Position: CHIEF EXECUTIVE OFFICER
Credential: NP
Phone: 443-802-5130