Basic Information
| Provider Information | |||||||||
| NPI: | 1457893489 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | MALLOY | ||||||||
| FirstName: | JASMIN | ||||||||
| MiddleName: | JELISSA | ||||||||
| NamePrefix: | MS. | ||||||||
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| Credential: | CRNA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 1011 NW 187TH AVE | ||||||||
| Address2: | |||||||||
| City: | PEMBROKE PINES | ||||||||
| State: | FL | ||||||||
| PostalCode: | 330292913 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9545546902 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 3476 S UNIVERSITY DR | ||||||||
| Address2: | |||||||||
| City: | DAVIE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 333282000 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9544754400 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 11/08/2016 | ||||||||
| LastUpdateDate: | 03/29/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 03/29/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | 041453148 | IL | N | Nursing Service Providers | Registered Nurse | 163WG0000X | 9314734 | FL | N | Nursing Service Providers | Registered Nurse | General Practice | 367500000X | 209016078 | IL | N | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered | 367500000X | 11014374 | FL | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Anesthetist, Certified Registered |
No ID Information.