Provider Demographics
NPI:1851914253
Name:LEE, EDNA MARIE
Entity Type:Individual
Prefix:MRS
First Name:EDNA
Middle Name:MARIE
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 1:374 KEARNEYSVILLE PIKE
Mailing Address - Street 2:
Mailing Address - City:KEARNEYSVILLE
Mailing Address - State:WV
Mailing Address - Zip Code:25430-4882
Mailing Address - Country:US
Mailing Address - Phone:304-886-6510
Mailing Address - Fax:
Practice Address - Street 1:374 KEARNEYSVILLE PIKE
Practice Address - Street 2:
Practice Address - City:KEARNEYSVILLE
Practice Address - State:WV
Practice Address - Zip Code:25430-4882
Practice Address - Country:US
Practice Address - Phone:304-886-6510
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-05-20
Last Update Date:2020-05-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant
Provider Identifiers
StateIdentifier IDID TypeIssuer
WV3747P1801XMedicaid