Healthcare Provider Details

I. General information

NPI: 1194342089
Provider Name (Legal Business Name): ANGELA MALCOMB RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/26/2020
Last Update Date: 06/26/2020
Certification Date: 06/26/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

804 BROAD ST
SUMMERSVILLE WV
26651-1796
US

IV. Provider business mailing address

804 BROAD ST
SUMMERSVILLE WV
26651-1796
US

V. Phone/Fax

Practice location:
  • Phone: 304-872-2090
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163WP0808X
TaxonomyPsychiatric/Mental Health Registered Nurse
License Number47293
License Number StateWV

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: