Provider Demographics
NPI:1164647632
Name:LEE, ALYCIA (MS, CDN)
Entity Type:Individual
Prefix:
First Name:ALYCIA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MS, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:128 E 83RD ST
Mailing Address - Street 2:
Mailing Address - City:NEW YORK
Mailing Address - State:NY
Mailing Address - Zip Code:10028-0812
Mailing Address - Country:US
Mailing Address - Phone:212-535-9385
Mailing Address - Fax:
Practice Address - Street 1:128 E 83RD ST
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10028-0812
Practice Address - Country:US
Practice Address - Phone:212-535-9385
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2007-04-17
Last Update Date:2016-04-15
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY001927133N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133N00000XDietary & Nutritional Service ProvidersNutritionist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NYA300024775Medicare PIN