Provider Demographics
NPI:1447387253
Name:MALCOLM, KIMBERLEY A
Entity Type:Individual
Prefix:
First Name:KIMBERLEY
Middle Name:A
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:206 MAIN ST # 4729
Mailing Address - Street 2:
Mailing Address - City:NORTHFIELD
Mailing Address - State:MA
Mailing Address - Zip Code:01360-1050
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:12 KINGSBURY ST
Practice Address - Street 2:
Practice Address - City:KEENE
Practice Address - State:NH
Practice Address - Zip Code:03431-3825
Practice Address - Country:US
Practice Address - Phone:603-352-0165
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2007-02-28
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NH2252225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NH08Y005291NH03OtherANTHEM
NH373100OtherMVP