Provider Demographics
NPI:1326311846
Name:LEE, KIESHA MAE (ATC, PES, NS)
Entity Type:Individual
Prefix:
First Name:KIESHA
Middle Name:MAE
Last Name:LEE
Suffix:
Gender:F
Credentials:ATC, PES, NS
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1 ENERGY PLAZA DR
Mailing Address - Street 2:
Mailing Address - City:JACKSON
Mailing Address - State:MI
Mailing Address - Zip Code:49201-2357
Mailing Address - Country:US
Mailing Address - Phone:717-651-9510
Mailing Address - Fax:
Practice Address - Street 1:1 ENERGY PLAZA DR
Practice Address - Street 2:
Practice Address - City:JACKSON
Practice Address - State:MI
Practice Address - Zip Code:49201-2357
Practice Address - Country:US
Practice Address - Phone:717-651-9510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-02-14
Last Update Date:2012-02-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC8302255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer