Provider Demographics
NPI:1144759069
Name:MODLIN, AMY MICHELLE (DO)
Entity type:Individual
Prefix:DR
First Name:AMY
Middle Name:MICHELLE
Last Name:MODLIN
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:628 E 12TH ST
Mailing Address - Street 2:
Mailing Address - City:WASHINGTON
Mailing Address - State:NC
Mailing Address - Zip Code:27889-3409
Mailing Address - Country:US
Mailing Address - Phone:252-975-4100
Mailing Address - Fax:
Practice Address - Street 1:628 E 12TH ST
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:NC
Practice Address - Zip Code:27889-3409
Practice Address - Country:US
Practice Address - Phone:252-975-4100
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-06-05
Last Update Date:2022-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC2020-00964207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine