Provider Demographics
NPI:1154139640
Name:MAGNOLIA HEALTH CARE LLC
Entity type:Organization
Organization Name:MAGNOLIA HEALTH CARE LLC
Other - Org Name:
Other - Org Type:
Authorized Official - Title/Position:FAMILY NURSE PRACTITIONER
Authorized Official - Prefix:DR
Authorized Official - First Name:SHAQUILLA
Authorized Official - Middle Name:
Authorized Official - Last Name:VAZQUEZ CLARK
Authorized Official - Suffix:
Authorized Official - Credentials:DNP, MSN, CRNP, FNP-
Authorized Official - Phone:410-793-3634
Mailing Address - Street 1:12530 FAIRWOOD PKWY
Mailing Address - Street 2:STE 102 #184
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20720-1992
Mailing Address - Country:US
Mailing Address - Phone:410-793-3634
Mailing Address - Fax:410-220-8162
Practice Address - Street 1:2407 BANEBERRY LANE
Practice Address - Street 2:
Practice Address - City:GAMBRILLS
Practice Address - State:MD
Practice Address - Zip Code:21054
Practice Address - Country:US
Practice Address - Phone:410-793-3634
Practice Address - Fax:410-220-8162
EIN:<UNAVAIL>
Is Organization Subpart?:No
Parent Organization LBN:
Parent Organization TIN:
Enumeration Date:2024-12-30
Last Update Date:2024-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Single Specialty