Provider Demographics
NPI:1760031371
Name:LEE, TERI GRACE (LMNTRD)
Entity Type:Individual
Prefix:
First Name:TERI
Middle Name:GRACE
Last Name:LEE
Suffix:
Gender:F
Credentials:LMNTRD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:807 CODY CIR
Mailing Address - Street 2:
Mailing Address - City:PAPILLION
Mailing Address - State:NE
Mailing Address - Zip Code:68046-3747
Mailing Address - Country:US
Mailing Address - Phone:402-990-9292
Mailing Address - Fax:
Practice Address - Street 1:807 CODY CIR
Practice Address - Street 2:
Practice Address - City:PAPILLION
Practice Address - State:NE
Practice Address - Zip Code:68046-3747
Practice Address - Country:US
Practice Address - Phone:402-331-4943
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-09-06
Last Update Date:2019-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NE764133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered