Provider Demographics
NPI:1497752042
Name:LEE, NIKKOL (DPT)
Entity Type:Individual
Prefix:MS
First Name:NIKKOL
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:DPT
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5501 N ORACLE RD
Mailing Address - Street 2:STE 101
Mailing Address - City:TUCSON
Mailing Address - State:AZ
Mailing Address - Zip Code:85704-3850
Mailing Address - Country:US
Mailing Address - Phone:520-293-5551
Mailing Address - Fax:520-293-6638
Practice Address - Street 1:1657 W GRANT RD
Practice Address - Street 2:
Practice Address - City:TUCSON
Practice Address - State:AZ
Practice Address - Zip Code:85745-1433
Practice Address - Country:US
Practice Address - Phone:520-670-9558
Practice Address - Fax:520-382-5550
Is Sole Proprietor?:No
Enumeration Date:2005-06-28
Last Update Date:2010-09-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZ5617225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
AZ86059251885745B003OtherTRICARE
AZ75272Medicare ID - Type Unspecified