Provider Demographics
NPI:1447790530
Name:MALIWA, BRANDERLY
Entity type:Individual
Prefix:
First Name:BRANDERLY
Middle Name:
Last Name:MALIWA
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 1:3311 HIGHWAY 5
Mailing Address - Street 2:SUITE C, ONE STOP MEDICAL CLINIC
Mailing Address - City:DOUGLASVILLE
Mailing Address - State:GA
Mailing Address - Zip Code:30135
Mailing Address - Country:US
Mailing Address - Phone:765-326-0148
Mailing Address - Fax:
Practice Address - Street 1:3311 HIGHWAY 5 STE C
Practice Address - Street 2:
Practice Address - City:DOUGLASVILLE
Practice Address - State:GA
Practice Address - Zip Code:30135-2375
Practice Address - Country:US
Practice Address - Phone:678-383-6944
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-03-08
Last Update Date:2018-06-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN224384363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1447790530Medicaid