Healthcare Provider Details

I. General information

NPI: 1225468804
Provider Name (Legal Business Name): SHAUNTELLE MALCOLM RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/19/2013
Last Update Date: 08/25/2022
Certification Date: 08/25/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1575 BLUE HILL AVE
MATTAPAN MA
02126-2122
US

IV. Provider business mailing address

1575 BLUE HILL AVE
MATTAPAN MA
02126-2122
US

V. Phone/Fax

Practice location:
  • Phone: 617-296-0061
  • Fax: 617-296-5408
Mailing address:
  • Phone: 617-296-0061
  • Fax: 617-296-5408

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN2278372
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberRN2278372
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: