MEDICARE: MAGNOLIA ADULT

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	363LA2200X	Adult Health Nurse Practitioner	ARNP3091702	FL

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	Y02HU	OTHER	FL	BLUE CROSS BLUE SHIELD

General Provider Information

NPI Number	:	1841611407
Entity Type Code	:	Organization
Provider Name (Legal Business Name)	:	MAGNOLIA ADULT

Provider Business Mailing Address
First Line	:	1211 SW BASCOM NORRIS DR STE 201
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-4916
Country	:	US
Telephone Number	:	375-755-3300
Fax Number	:	386-755-8595

Provider Business Practice Location Address
First Line	:	1211 SW BASCOM NORRIS DR STE 201
Second Line	:
City	:	LAKE CITY
State	:	FL
Zip	:	32025-4916
Country	:	US
Telephone Number	:	375-755-3300
Fax Number	:	386-755-8595

Authorized Official
Title or Position	:	OWNER
Name	:	MR. IRA D LEE
Credential	:	ARNP
Telephone Number	:	386-755-3300

Provider Enumeration Date	:	12/30/2013
Last Update Date	:	12/30/2013

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Directions to “MAGNOLIA ADULT ” Practice Location

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