Provider Demographics
NPI:1699354365
Name:MALONE, SANDRA S
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:S
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 1:23841 FRANK ST
Mailing Address - Street 2:
Mailing Address - City:NORTH OLMSTED
Mailing Address - State:OH
Mailing Address - Zip Code:44070-1378
Mailing Address - Country:US
Mailing Address - Phone:440-666-5731
Mailing Address - Fax:
Practice Address - Street 1:19106 INGLEWOOD AVE
Practice Address - Street 2:
Practice Address - City:ROCKY RIVER
Practice Address - State:OH
Practice Address - Zip Code:44116-2849
Practice Address - Country:US
Practice Address - Phone:440-666-5731
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-04-07
Last Update Date:2021-04-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes385HR2060XRespite Care FacilityRespite CareRespite Care, Intellectual and/or Developmental Disabilities, Child
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0066432Medicaid