Provider Demographics
NPI:1912019803
Name:LEE, PAMELA (MPH, RD, CDE)
Entity Type:Individual
Prefix:
First Name:PAMELA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:MPH, RD, CDE
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5767 W CENTURY BLVD
Mailing Address - Street 2:SUITE 200
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90045-5632
Mailing Address - Country:US
Mailing Address - Phone:310-828-7172
Mailing Address - Fax:310-828-8662
Practice Address - Street 1:1801 WILSHIRE BLVD
Practice Address - Street 2:100
Practice Address - City:SANTA MONICA
Practice Address - State:CA
Practice Address - Zip Code:90403-5609
Practice Address - Country:US
Practice Address - Phone:310-828-7172
Practice Address - Fax:310-828-8662
Is Sole Proprietor?:No
Enumeration Date:2006-08-31
Last Update Date:2010-07-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA803731207R00000X, 133V00000X, 133NN1002X, 132700000X, 133VN1006X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
No207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No132700000XDietary & Nutritional Service ProvidersDietary Manager
No133VN1006XDietary & Nutritional Service ProvidersDietitian, RegisteredNutrition, Metabolic
Provider Identifiers
StateIdentifier IDID TypeIssuer
CA0NT803731Medicaid
CA0NT803731Medicaid
CAP62945Medicare UPIN