Healthcare Provider Details

I. General information

NPI: 1730634692
Provider Name (Legal Business Name): EMILY SUZANNE MALCOLM R.R.T.
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/22/2016
Last Update Date: 08/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

510 BUTLER AVE
MARTINSBURG WV
25405-9990
US

IV. Provider business mailing address

238 LARRY WAY
BUNKER HILL WV
25413-3695
US

V. Phone/Fax

Practice location:
  • Phone: 304-263-0811
  • Fax:
Mailing address:
  • Phone: 304-676-0157
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code227900000X
TaxonomyRegistered Respiratory Therapist
License Number0117007451
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: