Healthcare Provider Details

I. General information

NPI: 1639281652
Provider Name (Legal Business Name): MAGNOLIA MEDICAL CLINIC P.A.
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 08/31/2006
Last Update Date: 03/10/2025
Certification Date: 03/10/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

319 GREEN ACRES RD STE 101
FORT WALTON BEACH FL
32547
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: 850-243-7681
  • Fax: 850-243-0471

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code261Q00000X
TaxonomyClinic/Center
License Number
License Number State

VIII. Authorized Official

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