Provider Demographics
NPI:1962281741
Name:DOUGLAS, MODESTA
Entity type:Individual
Prefix:
First Name:MODESTA
Middle Name:
Last Name:DOUGLAS
Suffix:
Gender:F
Credentials:
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 75
Mailing Address - Street 2:
Mailing Address - City:LEWISBURG
Mailing Address - State:OH
Mailing Address - Zip Code:45338-0075
Mailing Address - Country:US
Mailing Address - Phone:937-361-2178
Mailing Address - Fax:
Practice Address - Street 1:208 E SOUTH WATER ST
Practice Address - Street 2:
Practice Address - City:LEWISBURG
Practice Address - State:OH
Practice Address - Zip Code:45338-8093
Practice Address - Country:US
Practice Address - Phone:937-361-2178
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant