Healthcare Provider Details

I. General information

NPI: 1255418414
Provider Name (Legal Business Name): MILLICENT M MALCOLM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 11/01/2006
Last Update Date: 04/12/2017
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

520 SAYBROOK RD SUITE N100
MIDDLETOWN CT
06457-4700
US

IV. Provider business mailing address

28 CRESCENT ST
MIDDLETOWN CT
06457-3654
US

V. Phone/Fax

Practice location:
  • Phone: 860-344-1801
  • Fax: 860-358-8657
Mailing address:
  • Phone: 860-358-4820
  • Fax: 860-358-8661

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number002258
License Number StateCT
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number002258
License Number StateCT
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number002258
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: