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General NPI Number Information
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NPI Number | 1174522916
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Entity Type | Individual
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Provider Name | MODUPE D MCINTOSH CPNP
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Gender | Female
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Dates
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Enumeration Date | 07/14/2005
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Last Update Date | 03/20/2024
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Provider Practice Location Address
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Address Line | 13577 FEATHER SOUND DR
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City | CLEARWATER
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State | FL
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Zip | 33762-2258
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Country | US
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Telephone | 904-902-4408
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Fax | 904-420-4745
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Provider Business Mailing Address
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Address Line | 635 BEAVER RUIN RD NW SUITE B
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City | LILBURN
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State | GA
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Zip | 30047-3474
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Country | US
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Telephone | 678-807-2230
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Fax | 770-267-5710
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Authorized Official
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Title or Position |
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Name |
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Credential |
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Telephone |
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Scope of Practice (Provider's specialty)
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Taxonomy #1
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Taxonomy Code | 363LP0200X
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Taxonomy Name | Pediatric Nurse Practitioner
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License Number | RN092844
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License Number State | GA
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Taxonomy #2
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Taxonomy Code | 363LP0808X
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Taxonomy Name | Psychiatric/Mental Health Nurse Practitioner
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License Number | APRN11031023
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License Number State | FL
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