Provider Demographics
NPI:1619451010
Name:MALCOLM, MAXINE LORRAINE (RN)
Entity Type:Individual
Prefix:MRS
First Name:MAXINE
Middle Name:LORRAINE
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:MAXINE
Other - Middle Name:
Other - Last Name:HALL
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:MAXINE MALCOLM
Mailing Address - Street 1:440 SIXTH AVE
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-1202
Mailing Address - Country:US
Mailing Address - Phone:646-209-5163
Mailing Address - Fax:
Practice Address - Street 1:4462 PARK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10457-2438
Practice Address - Country:US
Practice Address - Phone:212-582-9100
Practice Address - Fax:212-956-0526
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-20
Last Update Date:2018-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY661248-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse