MEDICARE: JOSEPH MALCOLM NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209-024202	IL

General Provider Information

NPI Number	:	1467117994
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	JOSEPH MALCOLM NP

Provider Business Mailing Address
First Line	:	4147 CALLERY RD
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-5006
Country	:	US
Telephone Number	:	630-276-9363
Fax Number	:

Provider Business Practice Location Address
First Line	:	4147 CALLERY RD
Second Line	:
City	:	NAPERVILLE
State	:	IL
Zip	:	60564-5006
Country	:	US
Telephone Number	:	630-276-9363
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/31/2021
Last Update Date	:	10/31/2021

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