Provider Demographics
NPI:1831491059
Name:MODRZEJEWSKI, KAREN LYNN (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KAREN
Middle Name:LYNN
Last Name:MODRZEJEWSKI
Suffix:
Gender:F
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 188
Mailing Address - Street 2:
Mailing Address - City:MARANA
Mailing Address - State:AZ
Mailing Address - Zip Code:85653-0188
Mailing Address - Country:US
Mailing Address - Phone:520-682-4111
Mailing Address - Fax:520-818-3630
Practice Address - Street 1:13395 N MARANA MAIN ST BLDG B
Practice Address - Street 2:
Practice Address - City:MARANA
Practice Address - State:AZ
Practice Address - Zip Code:85653-7008
Practice Address - Country:US
Practice Address - Phone:520-682-1091
Practice Address - Fax:520-682-4132
Is Sole Proprietor?:No
Enumeration Date:2010-11-19
Last Update Date:2021-07-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAP10946363LP0808X
AZ114985163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ354315Medicaid