Provider Demographics
NPI:1821308743
Name:LEE, KYUNG JA
Entity Type:Individual
Prefix:MS
First Name:KYUNG JA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:75 MAIDEN LANE
Mailing Address - Street 2:
Mailing Address - City:NYC
Mailing Address - State:NY
Mailing Address - Zip Code:10038
Mailing Address - Country:US
Mailing Address - Phone:212-477-6100
Mailing Address - Fax:212-405-2395
Practice Address - Street 1:808 BROOK AVE
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10451
Practice Address - Country:US
Practice Address - Phone:718-665-2056
Practice Address - Fax:718-665-2725
Is Sole Proprietor?:No
Enumeration Date:2010-10-13
Last Update Date:2010-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY338487-1163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse