Provider Demographics
NPI:1467117994
Name:MALCOLM, JOSEPH (NP)
Entity Type:Individual
Prefix:
First Name:JOSEPH
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:M
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4147 CALLERY RD
Mailing Address - Street 2:
Mailing Address - City:NAPERVILLE
Mailing Address - State:IL
Mailing Address - Zip Code:60564-5006
Mailing Address - Country:US
Mailing Address - Phone:630-276-9363
Mailing Address - Fax:
Practice Address - Street 1:4147 CALLERY RD
Practice Address - Street 2:
Practice Address - City:NAPERVILLE
Practice Address - State:IL
Practice Address - Zip Code:60564-5006
Practice Address - Country:US
Practice Address - Phone:630-276-9363
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-10-31
Last Update Date:2021-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209-024202363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty