Provider Demographics
NPI:1922144799
Name:GARRETT-LEE, VIVIAN L (PA)
Entity Type:Individual
Prefix:
First Name:VIVIAN
Middle Name:L
Last Name:GARRETT-LEE
Suffix:
Gender:F
Credentials:PA
Other - Prefix:MRS
Other - First Name:VIVIAN
Other - Middle Name:L
Other - Last Name:GARRETT-LEE
Other - Suffix:
Other - Last Name Type:Professional Name
Other - Credentials:PA
Mailing Address - Street 1:10500 S CICERO AVE
Mailing Address - Street 2:
Mailing Address - City:OAK LAWN
Mailing Address - State:IL
Mailing Address - Zip Code:60453-5205
Mailing Address - Country:US
Mailing Address - Phone:708-424-1202
Mailing Address - Fax:708-424-1395
Practice Address - Street 1:10500 S CICERO AVE
Practice Address - Street 2:
Practice Address - City:OAK LAWN
Practice Address - State:IL
Practice Address - Zip Code:60453-5205
Practice Address - Country:US
Practice Address - Phone:708-424-1202
Practice Address - Fax:708-424-1395
Is Sole Proprietor?:No
Enumeration Date:2007-01-29
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363AM0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical