Provider Demographics
NPI:1598158719
Name:LEE, MELBA
Entity Type:Individual
Prefix:
First Name:MELBA
Middle Name:
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 1:29 BLACK COAL DRIVE
Mailing Address - Street 2:
Mailing Address - City:FORT WASHAKIE,
Mailing Address - State:WY
Mailing Address - Zip Code:82514
Mailing Address - Country:US
Mailing Address - Phone:307-332-7672
Mailing Address - Fax:307-335-7514
Practice Address - Street 1:29 BLACK COAL ROAD
Practice Address - Street 2:
Practice Address - City:FORT WASHAKIE,
Practice Address - State:WY
Practice Address - Zip Code:82514
Practice Address - Country:US
Practice Address - Phone:307-332-7672
Practice Address - Fax:307-335-7514
Is Sole Proprietor?:Yes
Enumeration Date:2015-03-12
Last Update Date:2015-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FLCRT13831247100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes247100000XTechnologists, Technicians & Other Technical Service ProvidersRadiologic Technologist
Provider Identifiers
StateIdentifier IDID TypeIssuer
FL215611OtherARRT