Provider Demographics
NPI:1215115092
Name:HANLEY, MODESTA S (FNP)
Entity type:Individual
Prefix:MRS
First Name:MODESTA
Middle Name:S
Last Name:HANLEY
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 1:526 TRAILSIDE WAY
Mailing Address - Street 2:
Mailing Address - City:STONE MTN
Mailing Address - State:GA
Mailing Address - Zip Code:30087-5448
Mailing Address - Country:US
Mailing Address - Phone:770-469-7487
Mailing Address - Fax:
Practice Address - Street 1:4030 LAWRENVILLE HWY
Practice Address - Street 2:GEORGIA CLINIC, PC
Practice Address - City:LILBURN
Practice Address - State:GA
Practice Address - Zip Code:30047
Practice Address - Country:US
Practice Address - Phone:770-921-4811
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-02-05
Last Update Date:2008-02-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN098782 NP363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily