Healthcare Provider Details

I. General information

NPI: 1215439690
Provider Name (Legal Business Name): DAWN MALCOM FNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 03/01/2018
Last Update Date: 06/28/2023
Certification Date: 06/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

106 AVENUE B SUITE B
BOGALUSA LA
70427
US

IV. Provider business mailing address

5959 S SHERWOOD FOREST BLVD
BATON ROUGE LA
70816-6038
US

V. Phone/Fax

Practice location:
  • Phone: 985-730-6950
  • Fax: 985-545-1036
Mailing address:
  • Phone: 225-526-0609
  • Fax: 225-965-9196

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number902463
License Number StateMS
# 2
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberAP09749
License Number StateLA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: