Provider Demographics
NPI:1487040663
Name:LEE, ALICE
Entity Type:Individual
Prefix:
First Name:ALICE
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 1:604 S MAIN ST
Mailing Address - Street 2:
Mailing Address - City:WATER VALLEY
Mailing Address - State:MS
Mailing Address - Zip Code:38965-3468
Mailing Address - Country:US
Mailing Address - Phone:662-473-4050
Mailing Address - Fax:662-473-4191
Practice Address - Street 1:604 S MAIN ST
Practice Address - Street 2:
Practice Address - City:WATER VALLEY
Practice Address - State:MS
Practice Address - Zip Code:38965-3468
Practice Address - Country:US
Practice Address - Phone:662-473-4050
Practice Address - Fax:662-473-4191
Is Sole Proprietor?:No
Enumeration Date:2015-04-14
Last Update Date:2015-04-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MS1001126133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered