Provider Demographics
NPI:1467226167
Name:LEE, BRANDON LUKAS (MS, RD, LDN, CCRP)
Entity Type:Individual
Prefix:MR
First Name:BRANDON
Middle Name:LUKAS
Last Name:LEE
Suffix:
Gender:M
Credentials:MS, RD, LDN, CCRP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:30 FLOWER AVE. E
Mailing Address - Street 2:
Mailing Address - City:WATERTOWN
Mailing Address - State:NY
Mailing Address - Zip Code:13601
Mailing Address - Country:US
Mailing Address - Phone:845-224-8937
Mailing Address - Fax:
Practice Address - Street 1:30 FLOWER AVE. E
Practice Address - Street 2:
Practice Address - City:WATERTOWN
Practice Address - State:NY
Practice Address - Zip Code:13601
Practice Address - Country:US
Practice Address - Phone:845-224-8937
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-11-13
Last Update Date:2023-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NCL007292133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered