MEDICARE: MAGNOLIA MENTAL HEALTH AND WELLNESS PLLC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LP0808X	Psychiatric/Mental Health Nurse Practitioner

General Provider Information

NPI Number	:	1366380248
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA MENTAL HEALTH AND WELLNESS PLLC

Provider Business Mailing Address
First Line	:	1110 COWAN RD STE B
Second Line	:	#202
City	:	GULFPORT
State	:	MS
Zip	:	39507-3441
Country	:	US
Telephone Number	:	228-338-6853
Fax Number	:	228-333-0682

Provider Business Practice Location Address
First Line	:	549 E PASS RD
Second Line	:
City	:	GULFPORT
State	:	MS
Zip	:	39507-3261
Country	:	US
Telephone Number	:	228-338-6853
Fax Number	:	228-333-0682

Authorized Official
Title or Position	:	OWNER
Name	:	CHARLOTTE AEGER ROSS
Credential	:	PMHNP
Telephone Number	:	228-338-6853

Provider Enumeration Date	:	03/23/2026
Last Update Date	:	03/23/2026

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