Provider Demographics
NPI:1760556575
Name:LEE, MARY (STNA)
Entity Type:Individual
Prefix:
First Name:MARY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:STNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:585 PALACE LN
Mailing Address - Street 2:
Mailing Address - City:GAHANNA
Mailing Address - State:OH
Mailing Address - Zip Code:43230-2323
Mailing Address - Country:US
Mailing Address - Phone:614-478-0899
Mailing Address - Fax:
Practice Address - Street 1:585 PALACE LN
Practice Address - Street 2:
Practice Address - City:GAHANNA
Practice Address - State:OH
Practice Address - Zip Code:43230-2323
Practice Address - Country:US
Practice Address - Phone:614-478-0899
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-11-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
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