Provider Demographics
NPI:1508040817
Name:LEE, NICOLE C (ANP)
Entity Type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:C
Last Name:LEE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-362-7260
Mailing Address - Fax:314-362-6288
Practice Address - Street 1:4921 PARKVIEW PL
Practice Address - Street 2:DIV SURG CT ADULT THORACIC, STE 8B
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1032
Practice Address - Country:US
Practice Address - Phone:314-362-7260
Practice Address - Fax:314-362-6288
Is Sole Proprietor?:No
Enumeration Date:2007-12-21
Last Update Date:2024-04-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO154756363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO420029012Medicaid
MO1508040817Medicaid