Provider Demographics
NPI:1972104453
Name:LEE, KYUNG AH
Entity Type:Individual
Prefix:
First Name:KYUNG
Middle Name:AH
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 1:1201 W VALENCIA DR SPC 1
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-3320
Mailing Address - Country:US
Mailing Address - Phone:562-290-3121
Mailing Address - Fax:
Practice Address - Street 1:1183 E FOOTHILL BLVD STE 135
Practice Address - Street 2:
Practice Address - City:UPLAND
Practice Address - State:CA
Practice Address - Zip Code:91786-4082
Practice Address - Country:US
Practice Address - Phone:909-931-1368
Practice Address - Fax:909-931-1372
Is Sole Proprietor?:No
Enumeration Date:2020-11-03
Last Update Date:2022-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95015267363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care