Provider Demographics
NPI:1821457607
Name:LEE, SUYEON
Entity Type:Individual
Prefix:
First Name:SUYEON
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 1:12112 ADRIAN ST
Mailing Address - Street 2:#6-112
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-4352
Mailing Address - Country:US
Mailing Address - Phone:213-379-3095
Mailing Address - Fax:
Practice Address - Street 1:12112 ADRIAN ST
Practice Address - Street 2:#6-112
Practice Address - City:GARDEN GROVE
Practice Address - State:CA
Practice Address - Zip Code:92840-4352
Practice Address - Country:US
Practice Address - Phone:213-379-3095
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-02-22
Last Update Date:2016-02-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95003748364SP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SP0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistPediatrics