Provider Demographics
NPI:1932699170
Name:LEE, JIN KYOUNG
Entity Type:Individual
Prefix:
First Name:JIN KYOUNG
Middle Name:
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 1:20204 ROCKY HILL RD APT DR2
Mailing Address - Street 2:
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-3007
Mailing Address - Country:US
Mailing Address - Phone:646-706-2063
Mailing Address - Fax:
Practice Address - Street 1:20204 ROCKY HILL RD APT DR2
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3007
Practice Address - Country:US
Practice Address - Phone:646-706-2063
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2018-05-14
Last Update Date:2018-05-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY039137225100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY370048990OtherLEARNER PERMIT