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General NPI Number Information
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NPI Number | 1639281652
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Entity Type | Organization
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Legal Business Name | MAGNOLIA MEDICAL CLINIC P.A.
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Dates
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Enumeration Date | 08/31/2006
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Last Update Date | 03/10/2025
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Provider Practice Location Address
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Address Line | 319 GREEN ACRES RD STE 101
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547
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Country | US
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Telephone | 850-243-7681
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Fax | 850-243-0471
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Provider Business Mailing Address
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Address Line | 319 GREEN ACRES RD STE 101
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City | FORT WALTON BEACH
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State | FL
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Zip | 32547-1170
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Country | US
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Telephone | 850-243-7681
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Fax | 850-243-0471
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Authorized Official
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Title or Position | PRACTICE ADMINISTRATOR
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Name | MRS. CRYSTAL WEATHERINGTON
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Credential |
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Telephone | 850-243-0520
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 261Q00000X
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Taxonomy Name | Clinic/Center
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License Number |
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License Number State |
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Taxonomy #2
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Taxonomy Code | 207Q00000X
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Taxonomy Name | Family Medicine Physician
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License Number |
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License Number State |
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