Provider Demographics
NPI:1245961341
Name:MODESITT, NICOLE (BCN)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:
Last Name:MODESITT
Suffix:
Gender:F
Credentials:BCN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7200 S ALTON WAY STE A320
Mailing Address - Street 2:
Mailing Address - City:CENTENNIAL
Mailing Address - State:CO
Mailing Address - Zip Code:80112-2254
Mailing Address - Country:US
Mailing Address - Phone:720-428-8312
Mailing Address - Fax:720-600-6946
Practice Address - Street 1:7200 S ALTON WAY STE A320
Practice Address - Street 2:
Practice Address - City:CENTENNIAL
Practice Address - State:CO
Practice Address - Zip Code:80112-2254
Practice Address - Country:US
Practice Address - Phone:720-428-8312
Practice Address - Fax:720-600-6946
Is Sole Proprietor?:No
Enumeration Date:2022-06-20
Last Update Date:2022-06-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
171400000X
COE6517247200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247200000XTechnologists, Technicians & Other Technical Service ProvidersTechnician, Other
No171400000XOther Service ProvidersHealth & Wellness Coach