| Doctor Name: | MS. MODUPE D MCINTOSH |
| NPI Number: | 1174522916 |
| Entity Type Code: | Individual (1) |
| Gender: | F |
| Credentials: | CPNP |
| License Number: | RN092844 |
| Business Practice Address: | 635 Beaver Ruin Rd Nw Suite B Lilburn, GA - 300473474 |
| Business Phone Number: | 6788072230 |
| Business Fax Number: | 7702675710 |
| Mailing Address: | 635 Beaver Ruin Rd Nw, Suite B LILBURN |
| State: | GA |
| Postal Code: | 300473474 |
| Phone Number: | 6788072230 |
| Fax Number: | 7702675710 |
| NPI Enumeration Date: | 07/14/2005 |
| NPI Last Update Date: | 12/30/2014 |
| Replacement NPI: | 0 |
| NPI Deactivation Date: | |
| NPI Reactivation Date: |
Taxonomy Information: | |
| Healthcare Provider Taxonomy: | 363LP0200X |
| License Number: | RN092844 |
| Healthcare Provider Taxonomy: (Secondary) | Y |
| State: | GA |
| Taxonomy Type: | Physician Assistants & Advanced Practice Nursing Providers |
| Taxonomy Classification: | Nurse Practitioner |
| Taxonomy Specialization: | Pediatrics |
| Taxonomy Definition: | |