Provider Demographics
NPI:1336316181
Name:LEE, MARY (FNP-BC)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:FNP-BC
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 4337
Mailing Address - Street 2:360 CR 1007
Mailing Address - City:FRISCO
Mailing Address - State:CO
Mailing Address - Zip Code:80443-4337
Mailing Address - Country:US
Mailing Address - Phone:970-668-4047
Mailing Address - Fax:
Practice Address - Street 1:360 PEAK ONE DRIVE
Practice Address - Street 2:SUITE 100
Practice Address - City:FRISCO
Practice Address - State:CO
Practice Address - Zip Code:80443
Practice Address - Country:US
Practice Address - Phone:970-668-4040
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-05-12
Last Update Date:2013-06-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO113720363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
CO35222581Medicaid