Healthcare Provider Details

I. General information

NPI: 1376822965
Provider Name (Legal Business Name): AMELIA RUTH MALCOM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/12/2011
Last Update Date: 08/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1075 S MAIN ST SUITE 100
MADISON GA
30650-2033
US

IV. Provider business mailing address

PO BOX 209
MADISON GA
30650-0209
US

V. Phone/Fax

Practice location:
  • Phone: 706-752-0322
  • Fax: 706-752-0325
Mailing address:
  • Phone: 706-752-0322
  • Fax: 706-752-0325

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number171386
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: