MEDICARE: EVETHA MALCOLM-THERIAULT RD

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	133V00000X	Registered Dietitian	DTND346	AK
2	133V00000X	Registered Dietitian	ND10329	FL
3	133V00000X	Registered Dietitian	DT92594	TX
4	133V00000X	Registered Dietitian	LD006224	GA

General Provider Information

NPI Number	:	1659891521
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	EVETHA MALCOLM-THERIAULT RD

Provider Business Mailing Address
First Line	:	3311 GULF BREEZE PKWY # 110
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32563-3351
Country	:	US
Telephone Number	:	850-339-0728
Fax Number	:

Provider Business Practice Location Address
First Line	:	3311 GULF BREEZE PKWY # 110
Second Line	:
City	:	GULF BREEZE
State	:	FL
Zip	:	32563-3351
Country	:	US
Telephone Number	:	850-339-0728
Fax Number	:

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

Provider Enumeration Date	:	06/22/2017
Last Update Date	:	01/23/2026

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