MEDICARE: MAGNIFICENT ADVANCED AESTHETICS 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	363LP2300X	Primary Care Nurse Practitioner

General Provider Information

NPI Number	:	1790417541
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNIFICENT ADVANCED AESTHETICS PLLC

Provider Business Mailing Address
First Line	:	333 E BETHANY DR STE J130
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75002-3826
Country	:	US
Telephone Number	:	972-741-0484
Fax Number	:

Provider Business Practice Location Address
First Line	:	333 E BETHANY DR STE J130
Second Line	:
City	:	ALLEN
State	:	TX
Zip	:	75002-3826
Country	:	US
Telephone Number	:	972-741-0484
Fax Number	:

Authorized Official
Title or Position	:	CEO
Name	:	MRS. MIREYA LISS
Credential	:	NP
Telephone Number	:	972-741-0484

Provider Enumeration Date	:	06/29/2022
Last Update Date	:	05/30/2026

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