Provider Demographics
NPI:1083037964
Name:LEE, GINA (PMHNP-BC &ANP-BC)
Entity Type:Individual
Prefix:
First Name:GINA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PMHNP-BC &ANP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3618 171ST ST
Mailing Address - Street 2:
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11358-2209
Mailing Address - Country:US
Mailing Address - Phone:917-566-7645
Mailing Address - Fax:
Practice Address - Street 1:5836 254TH ST
Practice Address - Street 2:
Practice Address - City:LITTLE NECK
Practice Address - State:NY
Practice Address - Zip Code:11362-2124
Practice Address - Country:US
Practice Address - Phone:917-566-7645
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2014-01-28
Last Update Date:2021-05-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF402513-1363LP0808X
NYF306733-1363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY04030104Medicaid