Provider Demographics
NPI:1508200148
Name:MODESTE, NIA (BS, MS)
Entity Type:Individual
Prefix:MS
First Name:NIA
Middle Name:
Last Name:MODESTE
Suffix:
Gender:F
Credentials:BS, MS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2003 FIFTH AVE
Mailing Address - Street 2:LL
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10035
Mailing Address - Country:US
Mailing Address - Phone:646-523-5481
Mailing Address - Fax:212-283-8109
Practice Address - Street 1:2003 FIFTH AVE
Practice Address - Street 2:LL
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10035
Practice Address - Country:US
Practice Address - Phone:646-523-5481
Practice Address - Fax:212-283-8109
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-25
Last Update Date:2013-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY713104131174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist