Provider Demographics
NPI:1679243307
Name:LEE, MELISSA SUJIN (MSN, AGPCNP-BC, RN)
Entity Type:Individual
Prefix:
First Name:MELISSA
Middle Name:SUJIN
Last Name:LEE
Suffix:
Gender:F
Credentials:MSN, AGPCNP-BC, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5233 MARYLAND AVE
Mailing Address - Street 2:
Mailing Address - City:LA CRESCENTA
Mailing Address - State:CA
Mailing Address - Zip Code:91214-1218
Mailing Address - Country:US
Mailing Address - Phone:818-245-0834
Mailing Address - Fax:
Practice Address - Street 1:2250 ALCAZAR ST
Practice Address - Street 2:CSC 200
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90089-1001
Practice Address - Country:US
Practice Address - Phone:323-442-2872
Practice Address - Fax:323-442-2082
Is Sole Proprietor?:No
Enumeration Date:2021-09-14
Last Update Date:2023-06-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95086641163W00000X
CA95017666363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse