Provider Demographics
NPI:1457893489
Name:MALLOY, JASMIN JELISSA (CRNA)
Entity Type:Individual
Prefix:MS
First Name:JASMIN
Middle Name:JELISSA
Last Name:MALLOY
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1011 NW 187TH AVE
Mailing Address - Street 2:
Mailing Address - City:PEMBROKE PINES
Mailing Address - State:FL
Mailing Address - Zip Code:33029-2913
Mailing Address - Country:US
Mailing Address - Phone:954-554-6902
Mailing Address - Fax:
Practice Address - Street 1:3476 S UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:DAVIE
Practice Address - State:FL
Practice Address - Zip Code:33328-2000
Practice Address - Country:US
Practice Address - Phone:954-475-4400
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-11-08
Last Update Date:2022-03-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041453148163W00000X
FL9314734163WG0000X
IL209016078367500000X
FL11014374367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse
No163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice