Healthcare Provider Details

I. General information

NPI: 1245675354
Provider Name (Legal Business Name): MALLESHA MALCOLM CNM, WHNP-BC
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: MALLESHA MALCOLM

II. Dates (important events)

Enumeration Date: 05/02/2013
Last Update Date: 01/07/2025
Certification Date: 01/07/2025
Deactivation Date: 01/23/2015
Reactivation Date: 10/11/2017

III. Provider practice location address

5141 BROADWAY # 1RW097
NEW YORK NY
10034-1159
US

IV. Provider business mailing address

5141 BROADWAY # 1RW097
NEW YORK NY
10034-1159
US

V. Phone/Fax

Practice location:
  • Phone: 212-932-4000
  • Fax:
Mailing address:
  • Phone: 212-932-4200
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number668050
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberR244748
License Number StateMD
# 3
Primary TaxonomyN
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number421305
License Number StateNY
# 4
Primary TaxonomyN
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License NumberCNM07597
License Number StateMD
# 5
Primary TaxonomyY
Taxonomy Code367A00000X
TaxonomyAdvanced Practice Midwife
License Number002274
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: