MEDICARE: MICHELLE MODINA NP

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	363L00000X	Nurse Practitioner	NP12537	CA
2	363LA2200X	Adult Health Nurse Practitioner	NP12537	CA
3	363LG0600X	Gerontology Nurse Practitioner	NP12537	CA
4	363LS0200X	School Nurse Practitioner	NP12537	CA
5	363LW0102X	Women's Health Nurse Practitioner	NP12537	CA

General Provider Information

NPI Number	:	1417106311
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MICHELLE MODINA NP

Provider Business Mailing Address
First Line	:	11529 JAMES ST
Second Line	:
City	:	CERRITOS
State	:	CA
Zip	:	90703-7410
Country	:	US
Telephone Number	:	562-402-4675
Fax Number	:	562-402-4675

Provider Business Practice Location Address
First Line	:	1230 W 3RD ST
Second Line	:	4TH FLOOR
City	:	LOS ANGELES
State	:	CA
Zip	:	90017-1408
Country	:	US
Telephone Number	:	213-481-2511
Fax Number	:	213-481-1913

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/16/2008
Last Update Date	:	09/16/2008

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Directions to “ MICHELLE MODINA NP” Practice Location

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