Healthcare Provider Details

I. General information

NPI: 1265326870
Provider Name (Legal Business Name): MAGNOLIA HEALTHCARE PROVIDERS
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/06/2025
Last Update Date: 06/06/2025
Certification Date: 06/06/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

201 GREENBRIER BLVD
COVINGTON LA
70433-7236
US

IV. Provider business mailing address

1752 OX BOW LN
COVINGTON LA
70433-7273
US

V. Phone/Fax

Practice location:
  • Phone: 985-224-4135
  • Fax: 985-781-4319
Mailing address:
  • Phone: 985-507-8436
  • Fax: 985-781-4319

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name: SHANI GORIO BOOTH
Title or Position: PSYCHIATRIC NURSE PRACTITIONER
Credential: APRN
Phone: 985-507-8346