Individual
LORI ANGELEENE MODLY
Active
Sole proprietor
No
Provider details
NPI number
Gender
F
Credential
CPNP
Contact information
Practice address
743 SPRING ST NE, GAINESVILLE, GA 30501-3715
(770) 535-3611
(770) 535-7092
Mailing address
PO BOX 658, GAINESVILLE, GA 30503-0658
(770) 718-1122
(770) 535-7445
Taxonomy
Speciality
Code
Description
License number
State
363LP0200X
Pediatric Nurse Practitioner
Primary
RN201247
GA
Other
Other identifiers
Code
Description
Identifier
Issuer
State
05
—
003116595A
—
GA
01
—
01467542
AMERIGROUP
GA
01
—
643406
WELLCARE
GA
Enumeration date
11/22/2011
Last updated
02/28/2012
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