Provider Demographics
NPI:1295303675
Name:LEA, MAGEN LYNN (FNP)
Entity type:Individual
Prefix:
First Name:MAGEN
Middle Name:LYNN
Last Name:LEA
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:503 GIVENS MULLINS RD
Mailing Address - Street 2:
Mailing Address - City:MONTICELLO
Mailing Address - State:MS
Mailing Address - Zip Code:39654-9169
Mailing Address - Country:US
Mailing Address - Phone:601-954-2850
Mailing Address - Fax:
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7200
Practice Address - Country:US
Practice Address - Phone:601-288-2100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-14
Last Update Date:2021-06-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS904682363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily