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Individual
THERESA MALCOM
Active
Individual
THERESA MALCOM
Active
Sole proprietor
Yes
Provider details
NPI number
Gender
F
Credential
FNP
Taxonomy
Speciality
Code
Description
License number
State
207Q00000X
Family Medicine Physician
F05220661
IN
363LF0000X
Family Nurse Practitioner
Primary
71012835A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
01
—
236040463
MEDICARE
—
05
—
300068982
—
IN
Enumeration date
06/22/2022
Last updated
01/11/2023
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