Provider Demographics
NPI:1841787553
Name:LEE, ETERNITY VICTORIA (LAT, ATC)
Entity Type:Individual
Prefix:MS
First Name:ETERNITY
Middle Name:VICTORIA
Last Name:LEE
Suffix:
Gender:F
Credentials:LAT, ATC
Other - Prefix:
Other - First Name:EVIE
Other - Middle Name:VICTORIA
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:615 ASPIRE CT APT 105
Mailing Address - Street 2:
Mailing Address - City:PLAINFIELD
Mailing Address - State:IN
Mailing Address - Zip Code:46168-5665
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:1555 S ODELL ST
Practice Address - Street 2:
Practice Address - City:BROWNSBURG
Practice Address - State:IN
Practice Address - Zip Code:46112-8041
Practice Address - Country:US
Practice Address - Phone:317-457-0906
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-04-18
Last Update Date:2021-11-10
Deactivation Date:2021-04-01
Deactivation Code:
Reactivation Date:2021-11-10
Provider Licenses
StateLicense IDTaxonomies
IN36003455A2255A2300X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer