Provider Demographics
NPI:1639816192
Name:MALCOLM, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MALCOLM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:500 CROSS ST
Mailing Address - Street 2:
Mailing Address - City:BIG STONE CITY
Mailing Address - State:SD
Mailing Address - Zip Code:57216-8237
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9219 WATER ST
Practice Address - Street 2:
Practice Address - City:MONTAGUE
Practice Address - State:MI
Practice Address - Zip Code:49437-9206
Practice Address - Country:US
Practice Address - Phone:231-893-6655
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-05-17
Last Update Date:2024-12-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist