MEDICARE: LIBBY ANNE MALCOLM

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	390200000X	Student in an Organized Health Care Education/Training Program

General Provider Information

NPI Number	:	1346188828
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	LIBBY ANNE MALCOLM

Provider Business Mailing Address
First Line	:	21380 GOULD RD
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-5238
Country	:	US
Telephone Number	:	315-783-3945
Fax Number	:

Provider Business Practice Location Address
First Line	:	1304 WASHINGTON ST
Second Line	:
City	:	WATERTOWN
State	:	NY
Zip	:	13601-4532
Country	:	US
Telephone Number	:	315-782-5700
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	03/24/2026
Last Update Date	:	03/24/2026

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Directions to “ LIBBY ANNE MALCOLM ” Practice Location

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