Provider Demographics
NPI:1811037690
Name:MILLICENT M MALCOLM LLC
Entity Type:Organization
Organization Name:MILLICENT M MALCOLM LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:OWNER
Authorized Official - Prefix:MRS
Authorized Official - First Name:MILLICENT
Authorized Official - Middle Name:MARIE
Authorized Official - Last Name:MALCOLM
Authorized Official - Suffix:
Authorized Official - Credentials:APRN
Authorized Official - Phone:860-614-8154
Mailing Address - Street 1:369 BAILEYVILLE RD
Mailing Address - Street 2:
Mailing Address - City:MIDDLEFIELD
Mailing Address - State:CT
Mailing Address - Zip Code:06455
Mailing Address - Country:US
Mailing Address - Phone:860-349-1116
Mailing Address - Fax:860-349-1116
Practice Address - Street 1:369 BAILEYVILLE RD
Practice Address - Street 2:
Practice Address - City:MIDDLEFIELD
Practice Address - State:CT
Practice Address - Zip Code:06455
Practice Address - Country:US
Practice Address - Phone:860-349-1116
Practice Address - Fax:860-349-1116
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2007-02-08
Last Update Date:2011-11-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT002258363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CT004208296Medicaid
CT500001929Medicare PIN