Provider Demographics
NPI:1619062023
Name:LEE, NANCY MARY (DPM)
Entity Type:Individual
Prefix:DR
First Name:NANCY
Middle Name:MARY
Last Name:LEE
Suffix:
Gender:F
Credentials:DPM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 S 20TH ST
Mailing Address - Street 2:SUITE B
Mailing Address - City:ROGERS
Mailing Address - State:AR
Mailing Address - Zip Code:72758-1104
Mailing Address - Country:US
Mailing Address - Phone:479-636-9393
Mailing Address - Fax:479-636-9341
Practice Address - Street 1:200 S 20TH ST
Practice Address - Street 2:SUITE B
Practice Address - City:ROGERS
Practice Address - State:AR
Practice Address - Zip Code:72758-1104
Practice Address - Country:US
Practice Address - Phone:479-636-9393
Practice Address - Fax:479-636-9341
Is Sole Proprietor?:Yes
Enumeration Date:2006-10-03
Last Update Date:2014-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL216004943213E00000X
332B00000X
AR259213E00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes213E00000XPodiatric Medicine & Surgery Service ProvidersPodiatrist
No332B00000XSuppliersDurable Medical Equipment & Medical Supplies
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL016004943OtherIL
IL016004943OtherIL
IL642600Medicare PIN
IL4595310001Medicare NSC
IL754250Medicare PIN