Provider Demographics
NPI:1558696104
Name:LEE, JODIE RAE (MSN,ARNP,CPNP)
Entity Type:Individual
Prefix:
First Name:JODIE
Middle Name:RAE
Last Name:LEE
Suffix:
Gender:F
Credentials:MSN,ARNP,CPNP
Other - Prefix:
Other - First Name:JODIE
Other - Middle Name:RAE
Other - Last Name:JOHNSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MSN, ARNP, CPNP
Mailing Address - Street 1:1200 PLEASANT ST
Mailing Address - Street 2:
Mailing Address - City:DES MOINES
Mailing Address - State:IA
Mailing Address - Zip Code:50309-1406
Mailing Address - Country:US
Mailing Address - Phone:515-241-6611
Mailing Address - Fax:515-241-6635
Practice Address - Street 1:1200 PLEASANT ST
Practice Address - Street 2:
Practice Address - City:DES MOINES
Practice Address - State:IA
Practice Address - Zip Code:50309-1406
Practice Address - Country:US
Practice Address - Phone:515-241-6611
Practice Address - Fax:515-241-6635
Is Sole Proprietor?:No
Enumeration Date:2009-10-14
Last Update Date:2017-02-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IAC-108517363LP0200X
MO20099027667363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
175150080OtherMEDICARE
IA1558696104Medicaid