Provider Demographics
NPI:1326745241
Name:MAGOVERN, MOLLY (FNP-C)
Entity Type:Individual
Prefix:
First Name:MOLLY
Middle Name:
Last Name:MAGOVERN
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:224-D CORNWALL STREET, SUITE 403
Mailing Address - Street 2:
Mailing Address - City:LEESBURG
Mailing Address - State:VA
Mailing Address - Zip Code:20176-2704
Mailing Address - Country:US
Mailing Address - Phone:703-737-6010
Mailing Address - Fax:571-291-9786
Practice Address - Street 1:4660 KENMORE AVENUE, SUITE 1210
Practice Address - Street 2:
Practice Address - City:ALEXANDIRA
Practice Address - State:VA
Practice Address - Zip Code:22304-1311
Practice Address - Country:US
Practice Address - Phone:703-461-0700
Practice Address - Fax:703-461-0803
Is Sole Proprietor?:No
Enumeration Date:2023-02-10
Last Update Date:2024-02-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024186492363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA1326745241Medicaid
VA30017582240003Medicaid