Provider Demographics
NPI:1942280508
Name:LEE, NICOLE JENNIFER (MD)
Entity Type:Individual
Prefix:MS
First Name:NICOLE
Middle Name:JENNIFER
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
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Other - Credentials:
Mailing Address - Street 1:410 MAPLE AVENUE WEST
Mailing Address - Street 2:STE. 5
Mailing Address - City:VIENNA
Mailing Address - State:VA
Mailing Address - Zip Code:22180
Mailing Address - Country:US
Mailing Address - Phone:703-938-2244
Mailing Address - Fax:703-938-3669
Practice Address - Street 1:410 MAPLE AVENUE WEST
Practice Address - Street 2:STE. 5
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22180
Practice Address - Country:US
Practice Address - Phone:703-938-2244
Practice Address - Fax:703-938-3669
Is Sole Proprietor?:No
Enumeration Date:2006-01-19
Last Update Date:2012-01-18
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
VA0101238041208000000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes208000000XAllopathic & Osteopathic PhysiciansPediatrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA010159407Medicaid