Healthcare Provider Details

I. General information

NPI: 1215604269
Provider Name (Legal Business Name): CHRISTINE MALCOLM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/26/2021
Last Update Date: 07/21/2023
Certification Date: 07/21/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

7 MAGAURAN DR STE 3
STAFFORD SPRINGS CT
06076-4040
US

IV. Provider business mailing address

7 MAGAURAN DR STE 3
STAFFORD SPRINGS CT
06076-4040
US

V. Phone/Fax

Practice location:
  • Phone: 860-684-5438
  • Fax:
Mailing address:
  • Phone: 860-684-5438
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number9865
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number9865
License Number StateCT
# 3
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number9865
License Number StateCT
# 4
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number9865
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: