Provider Demographics
NPI:1639340136
Name:LEE, ADRIENNE W (MD)
Entity Type:Individual
Prefix:
First Name:ADRIENNE
Middle Name:W
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1074 PATTERSON RD
Mailing Address - Street 2:
Mailing Address - City:KETTERING
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1522
Mailing Address - Country:US
Mailing Address - Phone:937-258-6330
Mailing Address - Fax:937-396-2242
Practice Address - Street 1:1074 PATTERSON RD
Practice Address - Street 2:
Practice Address - City:KETTERING
Practice Address - State:OH
Practice Address - Zip Code:45420-1522
Practice Address - Country:US
Practice Address - Phone:937-258-6330
Practice Address - Fax:937-396-2242
Is Sole Proprietor?:No
Enumeration Date:2008-03-12
Last Update Date:2024-02-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PAMD440300208000000X
OH35.120351208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH0075803Medicaid
PA1025033510001Medicaid
PA1025033510001Medicaid