Healthcare Provider Details

I. General information

NPI: 1811037690
Provider Name (Legal Business Name): MILLICENT M MALCOLM LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/08/2007
Last Update Date: 11/28/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

369 BAILEYVILLE RD
MIDDLEFIELD CT
06455
US

IV. Provider business mailing address

369 BAILEYVILLE RD
MIDDLEFIELD CT
06455
US

V. Phone/Fax

Practice location:
  • Phone: 860-349-1116
  • Fax: 860-349-1116
Mailing address:
  • Phone: 860-349-1116
  • Fax: 860-349-1116

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number002258
License Number StateCT

VIII. Authorized Official

Name: MRS. MILLICENT MARIE MALCOLM
Title or Position: OWNER
Credential: APRN
Phone: 860-614-8154