Provider Demographics
NPI:1780321216
Name:MALCOLM, SHELLEY M (MS, CN)
Entity type:Individual
Prefix:
First Name:SHELLEY
Middle Name:M
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:MS, CN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3261 67TH AVE SE
Mailing Address - Street 2:
Mailing Address - City:MERCER ISLAND
Mailing Address - State:WA
Mailing Address - Zip Code:98040-3307
Mailing Address - Country:US
Mailing Address - Phone:206-660-8088
Mailing Address - Fax:
Practice Address - Street 1:3261 67TH AVE SE
Practice Address - Street 2:
Practice Address - City:MERCER ISLAND
Practice Address - State:WA
Practice Address - Zip Code:98040-3307
Practice Address - Country:US
Practice Address - Phone:206-660-8088
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-16
Last Update Date:2022-05-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WA61224136133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist