MEDICARE: MS. HOLLY MARIE MALCOM RD, LD/N

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	133V00000X	Registered Dietitian	ND6224	FL

General Provider Information

NPI Number	:	1962826933
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. HOLLY MARIE MALCOM RD, LD/N

Provider Business Mailing Address
First Line	:	5000 NEW BEDFORD PL APT 320
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-4693
Country	:	US
Telephone Number	:	561-685-8165
Fax Number	:

Provider Business Practice Location Address
First Line	:	5000 NEW BEDFORD PL APT 320
Second Line	:
City	:	WINTER SPRINGS
State	:	FL
Zip	:	32708-4693
Country	:	US
Telephone Number	:	561-685-8165
Fax Number	:

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

Provider Enumeration Date	:	02/12/2014
Last Update Date	:	02/12/2014

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