Provider Demographics
NPI:1497750327
Name:LEE, SUSAN K (NP)
Entity Type:Individual
Prefix:
First Name:SUSAN
Middle Name:K
Last Name:LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:250 N SHADELAND AVE
Mailing Address - Street 2:
Mailing Address - City:INDIANAPOLIS
Mailing Address - State:IN
Mailing Address - Zip Code:46219-4959
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:995 S CLARIZZ BLVD
Practice Address - Street 2:
Practice Address - City:BLOOMINGTON
Practice Address - State:IN
Practice Address - Zip Code:47401-5588
Practice Address - Country:US
Practice Address - Phone:812-353-3060
Practice Address - Fax:812-353-5228
Is Sole Proprietor?:No
Enumeration Date:2005-06-16
Last Update Date:2022-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IN71000426A363L00000X
IN71000426363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IN200119700Medicaid
INS55575Medicare UPIN
IN200119700Medicaid
IN549210GGMedicare ID - Type Unspecified