Provider Demographics
NPI:1518471317
Name:LEE, CONNIE L (RN)
Entity Type:Individual
Prefix:
First Name:CONNIE
Middle Name:L
Last Name:LEE
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:29157 AZARA ST
Mailing Address - Street 2:
Mailing Address - City:MURRIETA
Mailing Address - State:CA
Mailing Address - Zip Code:92563-4429
Mailing Address - Country:US
Mailing Address - Phone:951-816-2182
Mailing Address - Fax:
Practice Address - Street 1:1370 S STATE ST STE B
Practice Address - Street 2:
Practice Address - City:SAN JACINTO
Practice Address - State:CA
Practice Address - Zip Code:92583-4922
Practice Address - Country:US
Practice Address - Phone:951-791-3596
Practice Address - Fax:951-791-3397
Is Sole Proprietor?:Yes
Enumeration Date:2017-12-01
Last Update Date:2017-12-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA826304163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes163W00000XNursing Service ProvidersRegistered NurseGroup - Single Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA826304OtherBOARD OF REGISTERED NURSING