Provider Demographics
NPI:1689014995
Name:LEE, SANDRA MICHELLE
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:MICHELLE
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 1:2221 BALFOUR RD
Mailing Address - Street 2:SUITE A
Mailing Address - City:BRENTWOOD
Mailing Address - State:CA
Mailing Address - Zip Code:94513-4932
Mailing Address - Country:US
Mailing Address - Phone:925-240-9116
Mailing Address - Fax:
Practice Address - Street 1:18555 VENTURA BLVD
Practice Address - Street 2:SUITE E
Practice Address - City:TARZANA
Practice Address - State:CA
Practice Address - Zip Code:91356-4191
Practice Address - Country:US
Practice Address - Phone:818-501-3376
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-07-01
Last Update Date:2015-06-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95001847363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily