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: 08/31/2026
Certification Date: 08/31/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

100 OWINGS CT STE 12
REISTERSTOWN MD
21136-6434
US

IV. Provider business mailing address

100 OWINGS CT STE 12
REISTERSTOWN MD
21136-6434
US

V. Phone/Fax

Practice location:
  • Phone: 410-220-5600
  • Fax: 833-955-3639
Mailing address:
  • Phone: 410-220-5600
  • Fax: 833-955-3639

VI. Provider taxonomy

Scope of Practice (Provider specialty)

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

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: