Healthcare Provider Details

I. General information

NPI: 1225908445
Provider Name (Legal Business Name): MAGNOLIA HEALTH CARE LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 11/11/2025
Last Update Date: 01/02/2026
Certification Date: 01/02/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2407 BANEBERRY LN
GAMBRILLS MD
21054-1992
US

IV. Provider business mailing address

12530 FAIRWOOD PKWY STE 102
BOWIE MD
20720-6357
US

V. Phone/Fax

Practice location:
  • Phone: 410-793-2634
  • Fax:
Mailing address:
  • Phone: 301-715-3010
  • Fax: 410-220-8162

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State
# 2
Primary TaxonomyY
Taxonomy Code163WW0000X
TaxonomyWound Care Registered Nurse
License Number
License Number State

VIII. Authorized Official

Name: SHAQUILLA VAZQUEZ CLARK
Title or Position: OWNER
Credential: DNP
Phone: 301-715-3010