Provider Demographics
NPI:1225371958
Name:LEE, RANISSA
Entity Type:Individual
Prefix:
First Name:RANISSA
Middle Name:
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:PO BOX 454
Mailing Address - Street 2:
Mailing Address - City:RED VALLEY
Mailing Address - State:AZ
Mailing Address - Zip Code:86544-0454
Mailing Address - Country:US
Mailing Address - Phone:505-608-5805
Mailing Address - Fax:505-564-2550
Practice Address - Street 1:1/2 MILE SW OF COVE CHAPTER HOUSE
Practice Address - Street 2:
Practice Address - City:RED VALLEY
Practice Address - State:AZ
Practice Address - Zip Code:86544
Practice Address - Country:US
Practice Address - Phone:505-608-5805
Practice Address - Fax:505-564-2550
Is Sole Proprietor?:Yes
Enumeration Date:2013-04-01
Last Update Date:2013-04-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ797515343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ797515Medicaid