Healthcare Provider Details

I. General information

NPI: 1831023639
Provider Name (Legal Business Name): MAGNOLIA BLOOM WOMEN'S HEALTH AND WELLNESS LLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 06/09/2026
Last Update Date: 10/02/2026
Certification Date: 09/29/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

443 HWY 18
BAY SPRINGS MS
39422-5187
US

IV. Provider business mailing address

443 HWY 18
BAY SPRINGS MS
39422-5187
US

V. Phone/Fax

Practice location:
  • Phone: 601-498-7853
  • Fax:
Mailing address:
  • Phone: 601-498-7853
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number
License Number StateNULL

VIII. Authorized Official

Name: SARAH RUSSELL
Title or Position: OWNER/AUTHORIZED OFFICIAL
Credential:
Phone: 601-498-7853