Provider Demographics
NPI:1093369852
Name:LEE, RYAN DAVID (LAT, ATC)
Entity Type:Individual
Prefix:MR
First Name:RYAN
Middle Name:DAVID
Last Name:LEE
Suffix:
Gender:M
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:414 PITMAN AVE
Mailing Address - Street 2:
Mailing Address - City:CAMPBELLSVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:42718-1730
Mailing Address - Country:US
Mailing Address - Phone:860-608-7942
Mailing Address - Fax:
Practice Address - Street 1:1 UNIVERSITY DR
Practice Address - Street 2:
Practice Address - City:CAMPBELLSVILLE
Practice Address - State:KY
Practice Address - Zip Code:42718-2799
Practice Address - Country:US
Practice Address - Phone:860-608-7942
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-30
Last Update Date:2021-08-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
2255A2300X
KYAT18792255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer