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General NPI Number Information
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NPI Number | 1295572451
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MOBILE MEDICAL, PLLC
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Dates
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Enumeration Date | 07/13/2024
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Last Update Date | 07/13/2024
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Provider Practice Location Address
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Address Line | 6475 PRINCESS ANN RD
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City | EVERGREEN
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State | NC
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Zip | 28438-9519
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Country | US
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Telephone | 910-770-3628
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Fax |
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Provider Business Mailing Address
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Address Line | 6475 PRINCESS ANN RD
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City | EVERGREEN
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State | NC
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Zip | 28438-9519
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Country | US
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Telephone | 910-770-3628
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Fax |
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Authorized Official
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Title or Position | OWNER
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Name | TINA NANCE
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Credential | FNP-C
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Telephone | 910-770-3628
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LF0000X
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Taxonomy Name | Family Nurse Practitioner
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License Number |
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License Number State |
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