Provider Demographics
NPI:1790050268
Name:LEE, AMY LYNN (ANP)
Entity Type:Individual
Prefix:MS
First Name:AMY
Middle Name:LYNN
Last Name:LEE
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
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Other - Credentials:
Mailing Address - Street 1:PO BOX 60352
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63160-0352
Mailing Address - Country:US
Mailing Address - Phone:314-454-7177
Mailing Address - Fax:888-425-7946
Practice Address - Street 1:12634 OLIVE BLVD
Practice Address - Street 2:DIV SURG COLON/RECTAL
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63141-6337
Practice Address - Country:US
Practice Address - Phone:314-454-7177
Practice Address - Fax:888-425-7946
Is Sole Proprietor?:No
Enumeration Date:2012-03-17
Last Update Date:2024-04-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2012008033363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO429593601Medicaid
ILENROLLEDMedicaid