Provider Demographics
NPI:1033477567
Name:MAGNOLIA ADULT
Entity Type:Organization
Organization Name:MAGNOLIA ADULT
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:PRESIDENT
Authorized Official - Prefix:
Authorized Official - First Name:IRA
Authorized Official - Middle Name:D
Authorized Official - Last Name:LEE
Authorized Official - Suffix:
Authorized Official - Credentials:ARNP-C
Authorized Official - Phone:386-755-3300
Mailing Address - Street 1:1140 SW BASCOM NORRIS DR STE 105
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-1329
Mailing Address - Country:US
Mailing Address - Phone:386-755-3300
Mailing Address - Fax:386-755-8595
Practice Address - Street 1:1140 SW BASCOM NORRIS DR STE 105
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-1329
Practice Address - Country:US
Practice Address - Phone:386-755-3300
Practice Address - Fax:386-755-8595
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2012-05-03
Last Update Date:2012-05-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLARNP3091702363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL305351200Medicaid