Provider Demographics
NPI:1326537408
Name:LEE, LATONJA
Entity Type:Individual
Prefix:
First Name:LATONJA
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 1:411 CLINTON AVE
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE CENTRE
Mailing Address - State:NY
Mailing Address - Zip Code:11570-3302
Mailing Address - Country:US
Mailing Address - Phone:516-425-3535
Mailing Address - Fax:
Practice Address - Street 1:1000 HEMPSTEAD AVE
Practice Address - Street 2:
Practice Address - City:ROCKVILLE CENTRE
Practice Address - State:NY
Practice Address - Zip Code:11570-1135
Practice Address - Country:US
Practice Address - Phone:516-323-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-05-04
Last Update Date:2021-07-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY20000083362255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY$$$$$$$$$OtherATHLETIC TRAINER