Provider Demographics
NPI:1588817803
Name:WEISE, LEE PONO-NALU (DO)
Entity Type:Individual
Prefix:
First Name:LEE
Middle Name:PONO-NALU
Last Name:WEISE
Suffix:
Gender:F
Credentials:DO
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:225 N WILLOW AVE
Mailing Address - Street 2:
Mailing Address - City:COOKEVILLE
Mailing Address - State:TN
Mailing Address - Zip Code:38501-2335
Mailing Address - Country:US
Mailing Address - Phone:931-528-8899
Mailing Address - Fax:
Practice Address - Street 1:225 N WILLOW AVE
Practice Address - Street 2:
Practice Address - City:COOKEVILLE
Practice Address - State:TN
Practice Address - Zip Code:38501-2335
Practice Address - Country:US
Practice Address - Phone:931-528-8899
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2008-10-30
Last Update Date:2016-10-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20A8737207Q00000X
TN1838207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine