Provider Demographics
NPI:1821121203
Name:LEE, KIMBERLY (NP)
Entity Type:Individual
Prefix:
First Name:KIMBERLY
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:324 WILMINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DAYTON
Mailing Address - State:OH
Mailing Address - Zip Code:45420-1890
Mailing Address - Country:US
Mailing Address - Phone:937-256-4490
Mailing Address - Fax:937-258-5478
Practice Address - Street 1:324 WILMINGTON AVE
Practice Address - Street 2:
Practice Address - City:DAYTON
Practice Address - State:OH
Practice Address - Zip Code:45420-1890
Practice Address - Country:US
Practice Address - Phone:937-256-4490
Practice Address - Fax:937-258-5478
Is Sole Proprietor?:No
Enumeration Date:2007-03-14
Last Update Date:2013-12-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OHNP 08489363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
OH2642680Medicaid
OH2642680Medicaid
OHQ57063Medicare UPIN
OH4859870001Medicare NSC