Healthcare Provider Details

I. General information

NPI: 1831692110
Provider Name (Legal Business Name): ANASTACIA P MODO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2018
Last Update Date: 04/22/2026
Certification Date: 04/22/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

2496 COLUMBIA DR
DECATUR GA
30034-1769
US

IV. Provider business mailing address

2704 HAYNESCREST DR
GRAYSON GA
30017-4280
US

V. Phone/Fax

Practice location:
  • Phone: 404-534-9222
  • Fax: 404-534-9063
Mailing address:
  • Phone: 678-834-3828
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberRN241610
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number241610
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: