Provider Demographics
NPI:1720402837
Name:MALONE, JOELLA
Entity Type:Individual
Prefix:
First Name:JOELLA
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 1:5438 YORK RD
Mailing Address - Street 2:
Mailing Address - City:BALTIMORE
Mailing Address - State:MD
Mailing Address - Zip Code:21212-3842
Mailing Address - Country:US
Mailing Address - Phone:410-542-8310
Mailing Address - Fax:
Practice Address - Street 1:5438 YORK RD
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21212-3842
Practice Address - Country:US
Practice Address - Phone:410-542-8310
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-02-10
Last Update Date:2014-02-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MD07692174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist