Healthcare Provider Details

I. General information

NPI: 1548043540
Provider Name (Legal Business Name): KANISHA IYONNA MALONE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/15/2023
Last Update Date: 08/15/2023
Certification Date: 08/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1329 BETHEL RD
COLUMBUS OH
43220-2611
US

IV. Provider business mailing address

1329 BETHEL RD
COLUMBUS OH
43220-2611
US

V. Phone/Fax

Practice location:
  • Phone: 502-416-4440
  • Fax:
Mailing address:
  • Phone: 502-416-4440
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041S0200X
TaxonomySchool Social Worker
License NumberS.2208163
License Number StateOH

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: