Healthcare Provider Details

I. General information

NPI: 1730916909
Provider Name (Legal Business Name): REINA MALCOLM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/19/2024
Last Update Date: 09/19/2024
Certification Date: 09/19/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

859 W 9TH ST
ST AUGUSTINE FL
32084-0728
US

IV. Provider business mailing address

859 W 9TH ST
ST AUGUSTINE FL
32084-0728
US

V. Phone/Fax

Practice location:
  • Phone: 904-377-1052
  • Fax:
Mailing address:
  • Phone: 904-377-1052
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code253Z00000X
TaxonomyIn Home Supportive Care Agency
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: