Healthcare Provider Details

I. General information

NPI: 1790994697
Provider Name (Legal Business Name): CHERYL L MALO-CLINES NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

Provider Other Name: CHERYL L MALO NP

II. Dates (important events)

Enumeration Date: 05/21/2007
Last Update Date: 08/14/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

446 OAK ST
BROOKINGS OR
97415-9612
US

IV. Provider business mailing address

PO BOX 6579
BROOKINGS OR
97415-0285
US

V. Phone/Fax

Practice location:
  • Phone: 541-412-8898
  • Fax:
Mailing address:
  • Phone: 541-412-8898
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number14753
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number00494
License Number StateNV
# 3
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number200950082NP
License Number StateOR

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: