Provider Demographics
NPI:1407242852
Name:MALONE, CARLA
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:
Last Name:MALONE
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 1:16500 N PARK DR APT 1720
Mailing Address - Street 2:
Mailing Address - City:SOUTHFIELD
Mailing Address - State:MI
Mailing Address - Zip Code:48075-4769
Mailing Address - Country:US
Mailing Address - Phone:313-463-9073
Mailing Address - Fax:
Practice Address - Street 1:16500 N PARK DR APT 1720
Practice Address - Street 2:
Practice Address - City:SOUTHFIELD
Practice Address - State:MI
Practice Address - Zip Code:48075-4769
Practice Address - Country:US
Practice Address - Phone:313-463-9073
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-04-13
Last Update Date:2015-04-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4703114515164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse