Healthcare Provider Details

I. General information

NPI: 1770342354
Provider Name (Legal Business Name): MAGNOLIA HEALTH, PLLC
Entity Type: Organization
Gender:
Sole Proprietor:

II. Dates (important events)

Enumeration Date: 03/18/2024
Last Update Date: 10/14/2024
Certification Date: 10/14/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

127 E TRADE ST STE B100
FOREST CITY NC
28043-2201
US

IV. Provider business mailing address

PO BOX 335
FOREST CITY NC
28043-0335
US

V. Phone/Fax

Practice location:
  • Phone: 828-220-4174
  • Fax:
Mailing address:
  • Phone: 828-220-4174
  • Fax: 833-972-5139

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number
License Number State

VIII. Authorized Official

Name: CLAYTON MOORE
Title or Position: OWNER
Credential: FNP
Phone: 828-220-4174