Provider Demographics
NPI:1225468804
Name:MALCOLM, SHAUNTELLE (RN)
Entity Type:Individual
Prefix:MS
First Name:SHAUNTELLE
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1575 BLUE HILL AVE
Mailing Address - Street 2:
Mailing Address - City:MATTAPAN
Mailing Address - State:MA
Mailing Address - Zip Code:02126-2122
Mailing Address - Country:US
Mailing Address - Phone:617-296-0061
Mailing Address - Fax:617-296-5408
Practice Address - Street 1:1575 BLUE HILL AVE
Practice Address - Street 2:
Practice Address - City:MATTAPAN
Practice Address - State:MA
Practice Address - Zip Code:02126-2122
Practice Address - Country:US
Practice Address - Phone:617-296-0061
Practice Address - Fax:617-296-5408
Is Sole Proprietor?:Yes
Enumeration Date:2013-11-19
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2278372163W00000X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse