Healthcare Provider Details

I. General information

NPI: 1053110619
Provider Name (Legal Business Name): MAGNOLIA MEDICAL CLINIC P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/07/2025
Last Update Date: 03/07/2025
Certification Date: 03/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4012 COMMONS DR W
DESTIN FL
32541-8422
US

IV. Provider business mailing address

319 GREEN ACRES RD STE 101
FORT WALTON BEACH FL
32547-1170
US

V. Phone/Fax

Practice location:
  • Phone: 850-243-7681
  • Fax: 850-243-0471
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State

VIII. Authorized Official

Name: CRYSTAL WEATHERINGTON
Title or Position: PRACTICE ADMINISTRATOR
Credential:
Phone: 850-243-0520