Provider Demographics
NPI:1891221024
Name:LEE, MAXINE
Entity Type:Individual
Prefix:
First Name:MAXINE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:MS
Other - First Name:MAXINE
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:FNP
Mailing Address - Street 1:13437 166TH PL
Mailing Address - Street 2:APT 4H
Mailing Address - City:JAMAICA
Mailing Address - State:NY
Mailing Address - Zip Code:11434-3852
Mailing Address - Country:US
Mailing Address - Phone:718-978-0984
Mailing Address - Fax:
Practice Address - Street 1:13966 35TH AVE
Practice Address - Street 2:
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-3524
Practice Address - Country:US
Practice Address - Phone:347-416-4108
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-05-09
Last Update Date:2017-05-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF338423363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily