Healthcare Provider Details

I. General information

NPI: 1659899375
Provider Name (Legal Business Name): CHELSEA DAWN MALINOWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 09/01/2017
Last Update Date: 05/10/2024
Certification Date: 05/10/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

105 CARNEGIE PL STE 103
FAYETTEVILLE GA
30214-5900
US

IV. Provider business mailing address

37 BRIDLEWOOD RD
SOUTH WINDSOR CT
06074-2513
US

V. Phone/Fax

Practice location:
  • Phone: 770-716-7999
  • Fax: 770-716-8444
Mailing address:
  • Phone: 860-424-6115
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number12.007207
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: