Provider Demographics
NPI:1689620650
Name:MALCOM, CLINT P (MH APRN)
Entity Type:Individual
Prefix:MR
First Name:CLINT
Middle Name:P
Last Name:MALCOM
Suffix:
Gender:M
Credentials:MH APRN
Other - Prefix:
Other - First Name:
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Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:2315 W 39TH ST
Mailing Address - Street 2:UNIT #6
Mailing Address - City:KEARNEY
Mailing Address - State:NE
Mailing Address - Zip Code:68845-8327
Mailing Address - Country:US
Mailing Address - Phone:308-233-3847
Mailing Address - Fax:308-233-5921
Practice Address - Street 1:2315 W 39TH ST
Practice Address - Street 2:UNIT #6
Practice Address - City:KEARNEY
Practice Address - State:NE
Practice Address - Zip Code:68845-8327
Practice Address - Country:US
Practice Address - Phone:308-233-3847
Practice Address - Fax:308-233-5921
Is Sole Proprietor?:Yes
Enumeration Date:2006-05-25
Last Update Date:2008-05-14
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
NE110744363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
NENA1006Medicare PIN