Provider Demographics
NPI:1699045898
Name:MODDRELL, AMBER (AA)
Entity type:Individual
Prefix:
First Name:AMBER
Middle Name:
Last Name:MODDRELL
Suffix:
Gender:F
Credentials:AA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:552 N COLORADO ST
Mailing Address - Street 2:
Mailing Address - City:KENNEWICK
Mailing Address - State:WA
Mailing Address - Zip Code:99336-7779
Mailing Address - Country:US
Mailing Address - Phone:808-284-7225
Mailing Address - Fax:
Practice Address - Street 1:552 N COLORADO ST
Practice Address - Street 2:
Practice Address - City:KENNEWICK
Practice Address - State:WA
Practice Address - Zip Code:99336-7779
Practice Address - Country:US
Practice Address - Phone:808-284-7225
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-01-04
Last Update Date:2012-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172V00000XOther Service ProvidersCommunity Health Worker
Provider Identifiers
StateIdentifier IDID TypeIssuer
26-3162747OtherTUTOR