Provider Demographics
NPI:1407444649
Name:MALONE, CANAAN
Entity Type:Individual
Prefix:
First Name:CANAAN
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 1:3100 KILPATRICK BLVD
Mailing Address - Street 2:
Mailing Address - City:MONROE
Mailing Address - State:LA
Mailing Address - Zip Code:71201-5156
Mailing Address - Country:US
Mailing Address - Phone:318-325-8050
Mailing Address - Fax:
Practice Address - Street 1:3100 KILPATRICK BLVD
Practice Address - Street 2:
Practice Address - City:MONROE
Practice Address - State:LA
Practice Address - Zip Code:71201-5156
Practice Address - Country:US
Practice Address - Phone:318-325-8050
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-01-04
Last Update Date:2022-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
LA171M00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator