Provider Demographics
NPI:1619518453
Name:LEE, THERESA CAROL (FNP-C)
Entity Type:Individual
Prefix:MRS
First Name:THERESA
Middle Name:CAROL
Last Name:LEE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:333 WILLOW ST APT 404
Mailing Address - Street 2:
Mailing Address - City:TEANECK
Mailing Address - State:NJ
Mailing Address - Zip Code:07666-4068
Mailing Address - Country:US
Mailing Address - Phone:847-877-6172
Mailing Address - Fax:
Practice Address - Street 1:420 GRAND AVE STE 101
Practice Address - Street 2:
Practice Address - City:ENGLEWOOD
Practice Address - State:NJ
Practice Address - Zip Code:07631-4141
Practice Address - Country:US
Practice Address - Phone:201-569-7044
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-02
Last Update Date:2019-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00967900363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily