MEDICARE: SOPHIA MAE MODICA RN

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	163W00000X	Registered Nurse	812012	NY

General Provider Information

NPI Number	:	1407545577
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	SOPHIA MAE MODICA RN

Provider Business Mailing Address
First Line	:	25 BAY DR
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-7303
Country	:	US
Telephone Number	:	631-809-1269
Fax Number	:

Provider Business Practice Location Address
First Line	:	25 BAY DR
Second Line	:
City	:	MASSAPEQUA
State	:	NY
Zip	:	11758-7303
Country	:	US
Telephone Number	:	631-809-1269
Fax Number	:

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

Provider Enumeration Date	:	05/04/2023
Last Update Date	:	05/04/2023

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