Provider Demographics
NPI:1609812205
Name:LEE, LAURA MAE (CRNA)
Entity Type:Individual
Prefix:
First Name:LAURA
Middle Name:MAE
Last Name:LEE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:20 DEER RUN TRL
Mailing Address - Street 2:
Mailing Address - City:SHARPSBURG
Mailing Address - State:GA
Mailing Address - Zip Code:30277-1994
Mailing Address - Country:US
Mailing Address - Phone:269-369-5639
Mailing Address - Fax:
Practice Address - Street 1:60 HOSPITAL RD
Practice Address - Street 2:
Practice Address - City:NEWNAN
Practice Address - State:GA
Practice Address - Zip Code:30263-1210
Practice Address - Country:US
Practice Address - Phone:269-369-5639
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-06-21
Last Update Date:2010-10-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL209005864367500000X
GARN201155367500000X
MI4704173262367500000X
IN28108068A367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA1609812205OtherBLUE CROSS BLUE SHEILD
GA355570547DMedicaid
GA202I436163Medicare PIN