Provider Demographics
NPI:1538906771
Name:MALMQUIST, GWENETH DELILAH (LE)
Entity type:Individual
Prefix:
First Name:GWENETH
Middle Name:DELILAH
Last Name:MALMQUIST
Suffix:
Gender:F
Credentials:LE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:159 N MARENGO AVE APT 102
Mailing Address - Street 2:
Mailing Address - City:PASADENA
Mailing Address - State:CA
Mailing Address - Zip Code:91101-4505
Mailing Address - Country:US
Mailing Address - Phone:909-257-7085
Mailing Address - Fax:
Practice Address - Street 1:1 W CALIFORNIA BLVD STE 228
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-3033
Practice Address - Country:US
Practice Address - Phone:909-206-2443
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-07-15
Last Update Date:2024-07-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAL9928247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other