Provider Demographics
NPI:1679716807
Name:MALMSTROM, NICHOLAS A (LMP)
Entity Type:Individual
Prefix:MR
First Name:NICHOLAS
Middle Name:A
Last Name:MALMSTROM
Suffix:
Gender:M
Credentials:LMP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:501 W 4TH AVE
Mailing Address - Street 2:
Mailing Address - City:TOPPENISH
Mailing Address - State:WA
Mailing Address - Zip Code:98948-1615
Mailing Address - Country:US
Mailing Address - Phone:509-865-3141
Mailing Address - Fax:509-865-7388
Practice Address - Street 1:501 W 4TH AVE
Practice Address - Street 2:
Practice Address - City:TOPPENISH
Practice Address - State:WA
Practice Address - Zip Code:98948-1615
Practice Address - Country:US
Practice Address - Phone:509-865-3141
Practice Address - Fax:509-865-7388
Is Sole Proprietor?:No
Enumeration Date:2009-04-17
Last Update Date:2009-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAMA60079246374700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374700000XNursing Service Related ProvidersTechnician