Healthcare Provider Details

I. General information

NPI: 1124765680
Provider Name (Legal Business Name): LAVON JEANINE MAGRUDER NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/17/2022
Last Update Date: 09/30/2025
Certification Date: 09/30/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5963 EXCHANGE DR STE 100
ELDERSBURG MD
21784-9256
US

IV. Provider business mailing address

9954 SHOSHONE WAY
RANDALLSTOWN MD
21133-1739
US

V. Phone/Fax

Practice location:
  • Phone: 410-549-0900
  • Fax:
Mailing address:
  • Phone: 443-204-1134
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberR118954
License Number StateMD
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberR118954
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: