Healthcare Provider Details

I. General information

NPI: 1508435884
Provider Name (Legal Business Name): NICOLE MODZELEWSKI
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/22/2021
Last Update Date: 06/22/2021
Certification Date: 06/22/2021
Deactivation Date:
Reactivation Date:

III. Provider practice location address

125 PARKER HILL AVE STE 2
BOSTON MA
02120-2865
US

IV. Provider business mailing address

153 DELANEY AVE
CHICOPEE MA
01013-1311
US

V. Phone/Fax

Practice location:
  • Phone: 617-754-5000
  • Fax:
Mailing address:
  • Phone: 413-426-3651
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363A00000X
TaxonomyPhysician Assistant
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: