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General NPI Number Information
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NPI Number | 1457893489
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Entity Type | Individual
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Provider Name | JASMIN JELISSA MALLOY CRNA
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Gender | Female
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Dates
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Enumeration Date | 11/08/2016
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Last Update Date | 07/18/2024
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Provider Practice Location Address
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Address Line | 1968 PEACHTREE RD NW
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City | ATLANTA
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State | GA
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Zip | 30309-1281
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Country | US
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Telephone | 404-605-3775
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Fax |
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Provider Business Mailing Address
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Address Line | 1011 NW 187TH AVE
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City | PEMBROKE PINES
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State | FL
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Zip | 33029-2913
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Country | US
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Telephone | 954-554-6902
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Fax |
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 209016078
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License Number State | IL
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Taxonomy #2
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | RN9314734
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License Number State | GA
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Taxonomy #3
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Taxonomy Code | 367500000X
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Taxonomy Name | Certified Registered Nurse Anesthetist
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License Number | 11014374
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License Number State | FL
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Taxonomy #4
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Taxonomy Code | 163W00000X
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Taxonomy Name | Registered Nurse
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License Number | 041453148
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License Number State | IL
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Taxonomy #5
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Taxonomy Code | 163WG0000X
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Taxonomy Name | General Practice Registered Nurse
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License Number | 9314734
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License Number State | FL
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