Provider Demographics
NPI:1003874595
Name:LEE, GWENDOLYN (NP)
Entity Type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1020 S PARK DR
Mailing Address - Street 2:
Mailing Address - City:PETERSBURG
Mailing Address - State:VA
Mailing Address - Zip Code:23805-2306
Mailing Address - Country:US
Mailing Address - Phone:804-957-6440
Mailing Address - Fax:
Practice Address - Street 1:411 OAK ST
Practice Address - Street 2:ATTN: CREDENTIALS
Practice Address - City:CINCINNATI
Practice Address - State:OH
Practice Address - Zip Code:45219-2598
Practice Address - Country:US
Practice Address - Phone:513-984-1800
Practice Address - Fax:513-984-4909
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-03
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0024166548363LA2200X
NYF303243-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health