Healthcare Provider Details

I. General information

NPI: 1194183780
Provider Name (Legal Business Name): IPATIA MAGNUS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 02/10/2016
Last Update Date: 02/22/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13910 FIVAY RD SUITE 1
HUDSON FL
34667-7154
US

IV. Provider business mailing address

13910 FIVAY RD SUITE 1
HUDSON FL
34667-7154
US

V. Phone/Fax

Practice location:
  • Phone: 727-863-0063
  • Fax: 727-862-7163
Mailing address:
  • Phone: 727-863-0063
  • Fax: 727-862-7163

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License Number1961592
License Number StateFL

VIII. Authorized Official

Name: DR. IPATIA MAGNUS
Title or Position: PHD, PMHNP-BC
Credential: PHD, DNP, FPMHNP-BC
Phone: 727-863-0063