Provider Demographics
NPI:1073811717
Name:PACE, LEE (FNP, OTR)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:
Last Name:PACE
Suffix:
Gender:M
Credentials:FNP, OTR
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2910 MAGNOLIA PL
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39402-2428
Mailing Address - Country:US
Mailing Address - Phone:662-610-0847
Mailing Address - Fax:601-469-9965
Practice Address - Street 1:6051 U S HIGHWAY 49
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-7201
Practice Address - Country:US
Practice Address - Phone:601-288-7000
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-03-04
Last Update Date:2021-03-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSOT1385225X00000X
NMCNP-02475363LF0000X
AZAP5005363LF0000X
MSR879013363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist