Provider Demographics
NPI:1962018309
Name:LEE, CARL LONELL
Entity Type:Individual
Prefix:
First Name:CARL
Middle Name:LONELL
Last Name:LEE
Suffix:
Gender:M
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1214 NORWOOD ST
Mailing Address - Street 2:
Mailing Address - City:MANSFIELD
Mailing Address - State:TX
Mailing Address - Zip Code:76063-2391
Mailing Address - Country:US
Mailing Address - Phone:630-770-2598
Mailing Address - Fax:
Practice Address - Street 1:4500 S LANCASTER RD
Practice Address - Street 2:
Practice Address - City:DALLAS
Practice Address - State:TX
Practice Address - Zip Code:75216-7167
Practice Address - Country:US
Practice Address - Phone:214-742-8387
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-09-21
Last Update Date:2020-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TX920410163WC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine