Provider Demographics
NPI:1245609478
Name:LEE, AMY (RD CD CDE)
Entity Type:Individual
Prefix:
First Name:AMY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RD CD CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:252 MCHENRY ST
Mailing Address - Street 2:
Mailing Address - City:BURLINGTON
Mailing Address - State:WI
Mailing Address - Zip Code:53105-1828
Mailing Address - Country:US
Mailing Address - Phone:262-767-6369
Mailing Address - Fax:
Practice Address - Street 1:252 MCHENRY ST
Practice Address - Street 2:
Practice Address - City:BURLINGTON
Practice Address - State:WI
Practice Address - Zip Code:53105-1828
Practice Address - Country:US
Practice Address - Phone:262-767-6369
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-09-17
Last Update Date:2020-05-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI814542133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered