1356669022 NPI number — MISS ANDREA LYNN MODICA RN

Table of content: MISS ANDREA LYNN MODICA RN (NPI 1356669022)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1356669022 NPI number — MISS ANDREA LYNN MODICA RN

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
MODICA
Provider First Name:
ANDREA
Provider Middle Name:
LYNN
Provider Name Prefix Text:
MISS
Provider Name Suffix Text:
Provider Credential Text:
RN
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1356669022
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
05/05/2010
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
327 GUNDERSEN DR
Provider Second Line Business Mailing Address:
SUITE A
Provider Business Mailing Address City Name:
CAROL STREAM
Provider Business Mailing Address State Name:
IL
Provider Business Mailing Address Postal Code:
60188-2402
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
630-784-3295
Provider Business Mailing Address Fax Number:
630-665-7764

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
327 GUNDERSEN DR
Provider Second Line Business Practice Location Address:
SUITE A
Provider Business Practice Location Address City Name:
CAROL STREAM
Provider Business Practice Location Address State Name:
IL
Provider Business Practice Location Address Postal Code:
60188-2402
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
630-784-3295
Provider Business Practice Location Address Fax Number:
630-665-7764
Provider Enumeration Date:
05/05/2010

Additional Information

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163W00000X , with the licence number:  041335707 , registered in the state of IL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 02233497 . This is a "BLUE CROSS BLUE SHIELD OF ILLINOIS" identifier , issued by the state of ( IL ) . This identifiers is of the category "OTHER".




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