Healthcare Provider Details

I. General information

NPI: 1700606563
Provider Name (Legal Business Name): MAGNOLIA HEALTH & WELLNESS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 10/15/2024
Last Update Date: 10/15/2024
Certification Date: 10/15/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11052 E SERAFINA AVE
MESA AZ
85212-5193
US

IV. Provider business mailing address

11052 E SERAFINA AVE
MESA AZ
85212-5193
US

V. Phone/Fax

Practice location:
  • Phone: 602-345-1192
  • Fax:
Mailing address:
  • Phone: 480-440-1131
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207QA0505X
TaxonomyAdult Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: NICOLE STRUTZENBERG
Title or Position: NURSE PRACTITIONER/OWNER
Credential: FNP-C
Phone: 480-440-1131