Provider Demographics
NPI:1790438281
Name:MODESTE, LEWANDA JAMILLE
Entity Type:Individual
Prefix:
First Name:LEWANDA
Middle Name:JAMILLE
Last Name:MODESTE
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 1:517 E 43RD ST
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11203-5715
Mailing Address - Country:US
Mailing Address - Phone:718-715-2112
Mailing Address - Fax:
Practice Address - Street 1:517 E 43RD ST
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11203-5715
Practice Address - Country:US
Practice Address - Phone:718-715-2112
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-02-03
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY763447163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse