Provider Demographics
NPI:1750355582
Name:MODELL, JOHN M (RN)
Entity type:Individual
Prefix:MR
First Name:JOHN
Middle Name:M
Last Name:MODELL
Suffix:
Gender:M
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1745 GUMTREE CT
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80906-7761
Mailing Address - Country:US
Mailing Address - Phone:719-579-0315
Mailing Address - Fax:
Practice Address - Street 1:7500 COCHRANE CIRCLE
Practice Address - Street 2:ATTN: COL MODELL USA MEDDAC
Practice Address - City:FORT CARSON
Practice Address - State:CO
Practice Address - Zip Code:80913
Practice Address - Country:US
Practice Address - Phone:719-526-7129
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-02-16
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA332458163WA2000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WA2000XNursing Service ProvidersRegistered NurseAdministrator