Provider Demographics
NPI:1639103096
Name:LEE, CARLA RAE (CFNP)
Entity Type:Individual
Prefix:
First Name:CARLA
Middle Name:RAE
Last Name:LEE
Suffix:
Gender:F
Credentials:CFNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1272 WALNUT ST
Mailing Address - Street 2:
Mailing Address - City:DAWSON
Mailing Address - State:MN
Mailing Address - Zip Code:56232-2333
Mailing Address - Country:US
Mailing Address - Phone:320-769-4393
Mailing Address - Fax:320-769-2972
Practice Address - Street 1:1272 WALNUT ST
Practice Address - Street 2:
Practice Address - City:DAWSON
Practice Address - State:MN
Practice Address - Zip Code:56232-2333
Practice Address - Country:US
Practice Address - Phone:320-769-4393
Practice Address - Fax:320-769-2972
Is Sole Proprietor?:No
Enumeration Date:2006-07-10
Last Update Date:2022-03-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MNR 113532-7363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
MN216066800Medicaid
MN50002716Medicare ID - Type UnspecifiedMEDICARE B