Provider Demographics
NPI:1689996621
Name:LEE, JONGMI (NP-C, AGPCNP-BC)
Entity Type:Individual
Prefix:MS
First Name:JONGMI
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NP-C, AGPCNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2623 SEDGWICK AVE
Mailing Address - Street 2:4D
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10468-3839
Mailing Address - Country:US
Mailing Address - Phone:929-352-0454
Mailing Address - Fax:929-352-0455
Practice Address - Street 1:2623 SEDGWICK AVE
Practice Address - Street 2:4D
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10468-3839
Practice Address - Country:US
Practice Address - Phone:929-352-0454
Practice Address - Fax:929-352-0455
Is Sole Proprietor?:Yes
Enumeration Date:2010-02-18
Last Update Date:2019-12-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY577428163W00000X
NY307088363LA2200X
NY342923363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
No363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult HealthGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY03274751Medicaid