MEDICARE: SHELLEY M MALCOLM MS, CN

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	133N00000X	Nutritionist	61224136	WA

General Provider Information

NPI Number	:	1780321216
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SHELLEY M MALCOLM MS, CN

Provider Business Mailing Address
First Line	:	3261 67TH AVE SE
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-3307
Country	:	US
Telephone Number	:	206-660-8088
Fax Number	:

Provider Business Practice Location Address
First Line	:	3261 67TH AVE SE
Second Line	:
City	:	MERCER ISLAND
State	:	WA
Zip	:	98040-3307
Country	:	US
Telephone Number	:	206-660-8088
Fax Number	:

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

Provider Enumeration Date	:	05/16/2022
Last Update Date	:	05/16/2022

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