Provider Demographics
NPI:1013083229
Name:MALCOLM, BENJAMIN DANIEL (FNP)
Entity type:Individual
Prefix:MR
First Name:BENJAMIN
Middle Name:DANIEL
Last Name:MALCOLM
Suffix:
Gender:
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 932958
Mailing Address - Street 2:
Mailing Address - City:CLEVELAND
Mailing Address - State:OH
Mailing Address - Zip Code:44193-0028
Mailing Address - Country:US
Mailing Address - Phone:615-425-4200
Mailing Address - Fax:
Practice Address - Street 1:1095 S MAIN ST
Practice Address - Street 2:
Practice Address - City:CENTERVILLE
Practice Address - State:OH
Practice Address - Zip Code:45458-3840
Practice Address - Country:US
Practice Address - Phone:937-439-8622
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-11-28
Last Update Date:2025-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHAPRN.CNP.15883363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily