Provider Demographics
NPI:1346069010
Name:MODUMO, NANCY (CNA)
Entity type:Individual
Prefix:MRS
First Name:NANCY
Middle Name:
Last Name:MODUMO
Suffix:
Gender:F
Credentials:CNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:91-1088 KAUNOLU ST
Mailing Address - Street 2:
Mailing Address - City:EWA BEACH
Mailing Address - State:HI
Mailing Address - Zip Code:96706-2823
Mailing Address - Country:US
Mailing Address - Phone:808-232-9202
Mailing Address - Fax:808-689-4727
Practice Address - Street 1:91-1088 KAUNOLU ST
Practice Address - Street 2:
Practice Address - City:EWA BEACH
Practice Address - State:HI
Practice Address - Zip Code:96706-2823
Practice Address - Country:US
Practice Address - Phone:808-232-9202
Practice Address - Fax:808-689-4727
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
HIH1020412221376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide