Provider Demographics
NPI:1275123150
Name:MALCOLM, HANAH JAYMES
Entity Type:Individual
Prefix:
First Name:HANAH
Middle Name:JAYMES
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:12193 CUSTER ST
Mailing Address - Street 2:
Mailing Address - City:YUCAIPA
Mailing Address - State:CA
Mailing Address - Zip Code:92399-4485
Mailing Address - Country:US
Mailing Address - Phone:909-499-0804
Mailing Address - Fax:
Practice Address - Street 1:12193 CUSTER ST
Practice Address - Street 2:
Practice Address - City:YUCAIPA
Practice Address - State:CA
Practice Address - Zip Code:92399-4485
Practice Address - Country:US
Practice Address - Phone:909-499-0804
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-25
Last Update Date:2024-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95221802163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse