Provider Demographics
NPI:1770648891
Name:MALCOLM, ELIZABETH MOORE (ANP-BC)
Entity Type:Individual
Prefix:MS
First Name:ELIZABETH
Middle Name:MOORE
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:ANP-BC
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Mailing Address - Street 1:4939 BRITTONFIELD PKWY. BLDG.B., SUITE 210
Mailing Address - Street 2:DR. DOUGLAS W. HALLIDAY MD, P.C.
Mailing Address - City:EAST SYRACUSE
Mailing Address - State:NY
Mailing Address - Zip Code:13057-9208
Mailing Address - Country:US
Mailing Address - Phone:315-471-8404
Mailing Address - Fax:315-701-4877
Practice Address - Street 1:4939 BRITTONFIELD PKWY. BLDG. B., SUITE 210
Practice Address - Street 2:DR. DOUGLAS W. HALLIDAY MD, P.C.
Practice Address - City:EAST SYRACUSE
Practice Address - State:NY
Practice Address - Zip Code:13057-9208
Practice Address - Country:US
Practice Address - Phone:315-471-8404
Practice Address - Fax:315-701-4877
Is Sole Proprietor?:No
Enumeration Date:2006-12-27
Last Update Date:2023-03-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF304384-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
2006007950OtherANCC CERTIFICATION
NY399466OtherMVP PROVIDER IDENTIFER NUMBER
NYFM2164123OtherDEA REGISTRATION