Healthcare Provider Details

I. General information

NPI: 1265066245
Provider Name (Legal Business Name): ASHLEY MALCHOW NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 02/27/2020
Last Update Date: 11/27/2023
Certification Date: 05/17/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

128 S LAKE AVE
PHILLIPS WI
54555-1318
US

IV. Provider business mailing address

128 S LAKE AVE
PHILLIPS WI
54555-1318
US

V. Phone/Fax

Practice location:
  • Phone: 715-339-3546
  • Fax: 715-339-3546
Mailing address:
  • Phone: 715-339-3546
  • Fax: 715-339-3546

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number58175
License Number StateMN
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number7386
License Number StateMN
# 3
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number11692
License Number StateWI

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: