Basic Information
Provider Information | |||||||||
NPI: | 1255418414 | ||||||||
EntityType: | 1 | ||||||||
ReplacementNPI: |   | ||||||||
OrganizationName: |   | ||||||||
LastName: | MALCOLM | ||||||||
FirstName: | MILLICENT | ||||||||
MiddleName: | M | ||||||||
NamePrefix: |   | ||||||||
NameSuffix: |   | ||||||||
Credential: | APRN | ||||||||
OtherOrganizationName: |   | ||||||||
OtherOrganizationType: |   | ||||||||
OtherLastName: |   | ||||||||
OtherFirstName: |   | ||||||||
OtherMiddleName: |   | ||||||||
OtherNamePrefix: |   | ||||||||
OtherNameSuffix: |   | ||||||||
OtherCredential: |   | ||||||||
OtherLastNameType: |   | ||||||||
Mailing Information | |||||||||
Address1: | 28 CRESCENT ST | ||||||||
Address2: |   | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064573654 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603584820 | ||||||||
FaxNumber: | 8603588661 | ||||||||
Practice Location | |||||||||
Address1: | 520 SAYBROOK RD | ||||||||
Address2: | SUITE N100 | ||||||||
City: | MIDDLETOWN | ||||||||
State: | CT | ||||||||
PostalCode: | 064574700 | ||||||||
CountryCode: | US | ||||||||
TelephoneNumber: | 8603441801 | ||||||||
FaxNumber: | 8603588657 | ||||||||
Other Information | |||||||||
ProviderEnumerationDate: | 11/01/2006 | ||||||||
LastUpdateDate: | 04/12/2017 | ||||||||
NPIDeactivationReasonCode: |   | ||||||||
NPIDeactivationDate: |   | ||||||||
NPIReactivationDate: |   | ||||||||
ProviderGenderCode: | F | ||||||||
AuthorizedOfficialLastName: |   | ||||||||
AuthorizedOfficialFirstName: |   | ||||||||
AuthorizedOfficialMiddleName: |   | ||||||||
AuthorizedOfficialTitleorPosition: |   | ||||||||
AuthorizedOfficialTelephone: |   | ||||||||
IsSoleProprietor: | N | ||||||||
IsOrganizationSubpart: |   | ||||||||
ParentOrganizationLBN: |   | ||||||||
AuthorizedOfficialNamePrefix: |   | ||||||||
AuthorizedOfficialNameSuffix: |   | ||||||||
AuthorizedOfficialCredential: |   | ||||||||
NPICertificationDate: |   |
Taxonomy Information
Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 002258 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family | 363L00000X | 002258 | CT | Y |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |   | 363LG0600X | 002258 | CT | N |   | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Gerontology |
ID Information
ID | Type | State | Issuer | Description | 4208296 | 05 | CT |   | MEDICAID | 004208296 | 05 | CT |   | MEDICAID |