Provider Demographics
NPI:1548749310
Name:LEE, TAMICA DEANDRA
Entity Type:Individual
Prefix:
First Name:TAMICA
Middle Name:DEANDRA
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:PO BOX 344
Mailing Address - Street 2:
Mailing Address - City:GLEN ST MARY
Mailing Address - State:FL
Mailing Address - Zip Code:32040-0344
Mailing Address - Country:US
Mailing Address - Phone:904-408-9062
Mailing Address - Fax:
Practice Address - Street 1:439 SW MICHIGAN ST
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32025-0440
Practice Address - Country:US
Practice Address - Phone:386-487-0800
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-08-12
Last Update Date:2019-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL105795376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide