Provider Demographics
NPI:1336169002
Name:MODRALL, JAMIE K (FNP)
Entity Type:Individual
Prefix:
First Name:JAMIE
Middle Name:K
Last Name:MODRALL
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18601 LYNDON B JOHNSON FWY STE 315
Mailing Address - Street 2:
Mailing Address - City:MESQUITE
Mailing Address - State:TX
Mailing Address - Zip Code:75150-5612
Mailing Address - Country:US
Mailing Address - Phone:972-686-1795
Mailing Address - Fax:972-686-1798
Practice Address - Street 1:18601 LYNDON B JOHNSON FWY STE 315
Practice Address - Street 2:
Practice Address - City:MESQUITE
Practice Address - State:TX
Practice Address - Zip Code:75150-5612
Practice Address - Country:US
Practice Address - Phone:972-686-1795
Practice Address - Fax:972-686-1798
Is Sole Proprietor?:No
Enumeration Date:2006-07-19
Last Update Date:2012-11-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX650239363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
TX041477302Medicaid
TX041477304Medicaid
TXTXB123453Medicare PIN
TX041477302Medicaid
TX041477304Medicaid