Healthcare Provider Details

I. General information

NPI: 1417106311
Provider Name (Legal Business Name): MICHELLE MODINA NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/16/2008
Last Update Date: 09/16/2008
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1230 W 3RD ST 4TH FLOOR
LOS ANGELES CA
90017-1408
US

IV. Provider business mailing address

11529 JAMES ST
CERRITOS CA
90703-7410
US

V. Phone/Fax

Practice location:
  • Phone: 213-481-2511
  • Fax: 213-481-1913
Mailing address:
  • Phone: 562-402-4675
  • Fax: 562-402-4675

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP12537
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberNP12537
License Number StateCA
# 3
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberNP12537
License Number StateCA
# 4
Primary TaxonomyN
Taxonomy Code363LS0200X
TaxonomySchool Nurse Practitioner
License NumberNP12537
License Number StateCA
# 5
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License NumberNP12537
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: