Provider Demographics
NPI:1467932228
Name:LEE, GRACE
Entity Type:Individual
Prefix:
First Name:GRACE
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 1:4140 W 190TH ST
Mailing Address - Street 2:
Mailing Address - City:TORRANCE
Mailing Address - State:CA
Mailing Address - Zip Code:90504-5513
Mailing Address - Country:US
Mailing Address - Phone:310-423-4700
Mailing Address - Fax:310-423-4711
Practice Address - Street 1:625 S FAIR OAKS AVE STE 270&380
Practice Address - Street 2:
Practice Address - City:PASADENA
Practice Address - State:CA
Practice Address - Zip Code:91105-2613
Practice Address - Country:US
Practice Address - Phone:424-314-0177
Practice Address - Fax:424-314-0180
Is Sole Proprietor?:No
Enumeration Date:2018-08-20
Last Update Date:2023-08-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA55812363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant