Provider Demographics
NPI:1467704882
Name:LEE, MARY REGINA (LPN)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:REGINA
Last Name:LEE
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:310 SE BROWN ST
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32025-5956
Mailing Address - Country:US
Mailing Address - Phone:386-961-9243
Mailing Address - Fax:
Practice Address - Street 1:310 SE BROWN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-5956
Practice Address - Country:US
Practice Address - Phone:386-961-9243
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-10-09
Last Update Date:2012-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL164W00000X164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse