Provider Demographics
NPI:1043698244
Name:MODLIN, MICHELLE RAE
Entity Type:Individual
Prefix:MRS
First Name:MICHELLE
Middle Name:RAE
Last Name:MODLIN
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1542 S BLOOMINGTON ST
Mailing Address - Street 2:
Mailing Address - City:GREENCASTLE
Mailing Address - State:IN
Mailing Address - Zip Code:46135-2212
Mailing Address - Country:US
Mailing Address - Phone:765-658-2700
Mailing Address - Fax:
Practice Address - Street 1:1542 S BLOOMINGTON ST
Practice Address - Street 2:
Practice Address - City:GREENCASTLE
Practice Address - State:IN
Practice Address - Zip Code:46135-2212
Practice Address - Country:US
Practice Address - Phone:765-658-2700
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-05-08
Last Update Date:2015-08-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN28189230A363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily