Individual
DIANNE R MODLESKI
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
NP
Contact information
Practice address
1633 N CAPITOL AVE, STE 322, INDIANAPOLIS, IN 46202-1476
(317) 962-2929
(317) 962-2070
Mailing address
250 N SHADELAND AVE, SUITE 130 - PROVIDER ENROLLMENT, INDIANAPOLIS, IN 46219-4959
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
71002179A
IN
363LA2200X
Adult Health Nurse Practitioner
Primary
71002179A
IN
363LG0600X
Gerontology Nurse Practitioner
71002179A
IN
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
200830870
—
IN
Enumeration date
08/13/2006
Last updated
10/23/2013
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