Provider Demographics
NPI:1871115444
Name:MODIC, MARY ELIZABETH
Entity type:Individual
Prefix:
First Name:MARY ELIZABETH
Middle Name:
Last Name:MODIC
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 1:4582 WINDSTREAM LN
Mailing Address - Street 2:
Mailing Address - City:BRECKSVILLE
Mailing Address - State:OH
Mailing Address - Zip Code:44141-2931
Mailing Address - Country:US
Mailing Address - Phone:440-838-8463
Mailing Address - Fax:
Practice Address - Street 1:OFFICE OF ADVANCED PRACTICE - P-32 9500 EUCLID AVE
Practice Address - Street 2:
Practice Address - City:CLEVELAND
Practice Address - State:OH
Practice Address - Zip Code:44195-0001
Practice Address - Country:US
Practice Address - Phone:216-444-9005
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-17
Last Update Date:2023-12-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OH147424364S00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364S00000XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse Specialist