Provider Demographics
NPI:1124765680
Name:MAGRUDER, LAVON JEANINE (NP)
Entity type:Individual
Prefix:MS
First Name:LAVON
Middle Name:JEANINE
Last Name:MAGRUDER
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9954 SHOSHONE WAY
Mailing Address - Street 2:
Mailing Address - City:RANDALLSTOWN
Mailing Address - State:MD
Mailing Address - Zip Code:21133-1739
Mailing Address - Country:US
Mailing Address - Phone:443-204-1134
Mailing Address - Fax:
Practice Address - Street 1:5963 EXCHANGE DR STE 100
Practice Address - Street 2:
Practice Address - City:ELDERSBURG
Practice Address - State:MD
Practice Address - Zip Code:21784-9256
Practice Address - Country:US
Practice Address - Phone:410-549-0900
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-17
Last Update Date:2022-05-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR118954363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner