Provider Demographics
NPI:1437878063
Name:MALCOLM, MIKAYLA ELISE (MD)
Entity Type:Individual
Prefix:
First Name:MIKAYLA
Middle Name:ELISE
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2400 S BAY AVE
Mailing Address - Street 2:
Mailing Address - City:SANFORD
Mailing Address - State:FL
Mailing Address - Zip Code:32771-4554
Mailing Address - Country:US
Mailing Address - Phone:407-454-1801
Mailing Address - Fax:
Practice Address - Street 1:2400 S BAY AVE
Practice Address - Street 2:
Practice Address - City:SANFORD
Practice Address - State:FL
Practice Address - Zip Code:32771-4554
Practice Address - Country:US
Practice Address - Phone:407-454-1801
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-08-25
Last Update Date:2022-08-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLBACB821926106S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes106S00000XBehavioral Health & Social Service ProvidersBehavior Technician