Provider Demographics
NPI:1275184343
Name:LEE, ETHEL
Entity Type:Individual
Prefix:
First Name:ETHEL
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 1:12605 SANDPINE RESERVE PL
Mailing Address - Street 2:
Mailing Address - City:GIBSONTON
Mailing Address - State:FL
Mailing Address - Zip Code:33534-5553
Mailing Address - Country:US
Mailing Address - Phone:850-597-4803
Mailing Address - Fax:
Practice Address - Street 1:12605 SANDPINE RESERVE PL
Practice Address - Street 2:
Practice Address - City:GIBSONTON
Practice Address - State:FL
Practice Address - Zip Code:33534-5553
Practice Address - Country:US
Practice Address - Phone:850-597-4803
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-09-20
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747A0650XNursing Service Related ProvidersTechnicianAttendant Care Provider