Provider Demographics
NPI:1689022279
Name:PHILIP-ROUSSEAU, MAGNOLITA (AGNP-C)
Entity Type:Individual
Prefix:
First Name:MAGNOLITA
Middle Name:
Last Name:PHILIP-ROUSSEAU
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:MAGNOLITA
Other - Middle Name:
Other - Last Name:BONHEUR
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:AGNP-C
Mailing Address - Street 1:988 BROADWAY
Mailing Address - Street 2:
Mailing Address - City:BAYONNE
Mailing Address - State:NJ
Mailing Address - Zip Code:07002-4036
Mailing Address - Country:US
Mailing Address - Phone:201-339-6111
Mailing Address - Fax:
Practice Address - Street 1:988 BROADWAY
Practice Address - Street 2:
Practice Address - City:BAYONNE
Practice Address - State:NJ
Practice Address - Zip Code:07002-4036
Practice Address - Country:US
Practice Address - Phone:201-339-6111
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-25
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00638800363LG0600X, 364SG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
No364SG0600XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistGerontology