Provider Demographics
NPI:1891781605
Name:LEE, BRENDA W (MSN ARNP)
Entity Type:Individual
Prefix:
First Name:BRENDA
Middle Name:W
Last Name:LEE
Suffix:
Gender:F
Credentials:MSN ARNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5775 WAYZATA BLVD STE 400
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS PARK
Mailing Address - State:MN
Mailing Address - Zip Code:55416-1271
Mailing Address - Country:US
Mailing Address - Phone:952-905-5602
Mailing Address - Fax:
Practice Address - Street 1:909 S 336TH ST STE B101
Practice Address - Street 2:
Practice Address - City:FEDERAL WAY
Practice Address - State:WA
Practice Address - Zip Code:98003-7394
Practice Address - Country:US
Practice Address - Phone:253-839-8779
Practice Address - Fax:253-941-6941
Is Sole Proprietor?:No
Enumeration Date:2005-09-27
Last Update Date:2020-03-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WAAP30006306363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
WA0286221OtherSTATE L&I
WA9636929Medicaid
WAG8904922Medicare PIN
WA8857752Medicare PIN
WA0286221OtherSTATE L&I