Provider Demographics
NPI:1629323431
Name:LEE, LEKEYA
Entity Type:Individual
Prefix:
First Name:LEKEYA
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 1:5609 W THURSTON AVE
Mailing Address - Street 2:
Mailing Address - City:MILWAUKEE
Mailing Address - State:WI
Mailing Address - Zip Code:53218-2433
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5609 W THURSTON AVE
Practice Address - Street 2:
Practice Address - City:MILWAUKEE
Practice Address - State:WI
Practice Address - Zip Code:53218-2433
Practice Address - Country:US
Practice Address - Phone:414-573-1305
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-17
Last Update Date:2012-07-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator
No172V00000XOther Service ProvidersCommunity Health Worker
No372500000XNursing Service Related ProvidersChore Provider
Provider Identifiers
StateIdentifier IDID TypeIssuer
WI1760795322Medicaid