Provider Demographics
NPI:1093133571
Name:LEE, GLENNA PYO (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:GLENNA
Middle Name:PYO
Last Name:LEE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 HOLLOWAY AVE
Mailing Address - Street 2:
Mailing Address - City:SAN FRANCISCO
Mailing Address - State:CA
Mailing Address - Zip Code:94132-1722
Mailing Address - Country:US
Mailing Address - Phone:510-326-6694
Mailing Address - Fax:
Practice Address - Street 1:1600 HOLLOWAY AVE
Practice Address - Street 2:
Practice Address - City:SAN FRANCISCO
Practice Address - State:CA
Practice Address - Zip Code:94132-1722
Practice Address - Country:US
Practice Address - Phone:510-326-6694
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2014-04-02
Last Update Date:2015-03-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95000125363LW0102X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LW0102XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerWomen's Health