=====================================================
General NPI Number Information
=====================================================
NPI Number | 1972103661
-----------------------------------------------------
Entity Type | Organization
-----------------------------------------------------
Legal Business Name | MAGNOLIA FAMILY HEALTH LLC
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 10/30/2020
-----------------------------------------------------
Last Update Date | 10/21/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 121 E 1ST AVE # AVW
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21550-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-759-3800
-----------------------------------------------------
Fax | 301-777-7455
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 121 E 1ST AVE
-----------------------------------------------------
City | OAKLAND
-----------------------------------------------------
State | MD
-----------------------------------------------------
Zip | 21550-2728
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 301-759-3800
-----------------------------------------------------
Fax | 301-777-7455
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position | OWNER
-----------------------------------------------------
Name | FAITH ANN RODEHEAVER
-----------------------------------------------------
Credential | CRNP
-----------------------------------------------------
Telephone | 301-759-3800
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LP2300X
-----------------------------------------------------
Taxonomy Name | Primary Care Nurse Practitioner
-----------------------------------------------------
License Number |
-----------------------------------------------------
License Number State |
-----------------------------------------------------