Provider Demographics
NPI:1447213350
Name:LEE, SUSAN (NNP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NNP
Other - Prefix:
Other - First Name:SUSAN
Other - Middle Name:
Other - Last Name:SWEENEY
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:NNP
Mailing Address - Street 1:PO BOX 25483
Mailing Address - Street 2:
Mailing Address - City:WOODBURY
Mailing Address - State:MN
Mailing Address - Zip Code:55125-0483
Mailing Address - Country:US
Mailing Address - Phone:651-341-7199
Mailing Address - Fax:
Practice Address - Street 1:1655 BEAM AVE
Practice Address - Street 2:SUITE 302
Practice Address - City:MAPLEWOOD
Practice Address - State:MN
Practice Address - Zip Code:55109-1163
Practice Address - Country:US
Practice Address - Phone:651-232-7831
Practice Address - Fax:651-232-7826
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-04-11
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR166902-6363LN0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LN0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerNeonatal
Provider Identifiers
StateIdentifier IDID TypeIssuer
MNQ29302Medicare UPIN