Provider Demographics
NPI:1154051159
Name:LEE, NICOLE D
Entity Type:Individual
Prefix:
First Name:NICOLE
Middle Name:D
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1301 N COLUMBIA RD, STOP 9037
Mailing Address - Street 2:UND DEPARTMENT OF SURGERY
Mailing Address - City:GRAND FORKS
Mailing Address - State:ND
Mailing Address - Zip Code:58202-9037
Mailing Address - Country:US
Mailing Address - Phone:701-777-3069
Mailing Address - Fax:
Practice Address - Street 1:1301 N COLUMBIA RD, STOP 9037
Practice Address - Street 2:UND DEPARTMENT OF SURGERY
Practice Address - City:GRAND FORKS
Practice Address - State:ND
Practice Address - Zip Code:58202-9037
Practice Address - Country:US
Practice Address - Phone:701-777-3069
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-13
Last Update Date:2022-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDRL18550208600000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208600000XAllopathic & Osteopathic PhysiciansSurgery