Provider Demographics
NPI:1336699420
Name:MALCOLM, DEJA (LPN)
Entity Type:Individual
Prefix:MRS
First Name:DEJA
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:MS
Other - First Name:DEJA
Other - Middle Name:
Other - Last Name:EDWARDS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:1772 ROUTE 300 APT 4
Mailing Address - Street 2:
Mailing Address - City:NEWBURGH
Mailing Address - State:NY
Mailing Address - Zip Code:12550-8930
Mailing Address - Country:US
Mailing Address - Phone:845-500-2609
Mailing Address - Fax:
Practice Address - Street 1:1772 ROUTE 300 APT 4
Practice Address - Street 2:
Practice Address - City:NEWBURGH
Practice Address - State:NY
Practice Address - Zip Code:12550-8930
Practice Address - Country:US
Practice Address - Phone:845-500-2609
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-12
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY326426-1164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse