Healthcare Provider Details

I. General information

NPI: 1932753324
Provider Name (Legal Business Name): MARY THERESE MALCOLM CNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/24/2019
Last Update Date: 03/16/2020
Certification Date: 03/16/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

55 HIGHLAND AVE STE 101
SALEM MA
01970-2100
US

IV. Provider business mailing address

14 BRISTOL AVE
SWAMPSCOTT MA
01907-1131
US

V. Phone/Fax

Practice location:
  • Phone: 978-741-4171
  • Fax: 978-741-4283
Mailing address:
  • Phone: 617-697-1307
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WH0200X
TaxonomyHome Health Registered Nurse
License NumberRN257184
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN257184
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: