Provider Demographics
NPI:1578045647
Name:LEE, KYUNG LAE (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:KYUNG LAE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6771 WARNER AVE UNIT 2035
Mailing Address - Street 2:
Mailing Address - City:HUNTINGTON BEACH
Mailing Address - State:CA
Mailing Address - Zip Code:92647-9443
Mailing Address - Country:US
Mailing Address - Phone:213-595-2123
Mailing Address - Fax:
Practice Address - Street 1:6771 WARNER AVE UNIT 2035
Practice Address - Street 2:
Practice Address - City:HUNTINGTON BEACH
Practice Address - State:CA
Practice Address - Zip Code:92647-9443
Practice Address - Country:US
Practice Address - Phone:213-595-2123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-09-05
Last Update Date:2019-05-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95008938363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner