Provider Demographics
NPI:1972968105
Name:LEE, AMANDA
Entity Type:Individual
Prefix:
First Name:AMANDA
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 1:35 TRACEY ANN CT
Mailing Address - Street 2:
Mailing Address - City:NAUGATUCK
Mailing Address - State:CT
Mailing Address - Zip Code:06770-3465
Mailing Address - Country:US
Mailing Address - Phone:203-525-6919
Mailing Address - Fax:
Practice Address - Street 1:35 TRACEY ANN CT
Practice Address - Street 2:
Practice Address - City:NAUGATUCK
Practice Address - State:CT
Practice Address - Zip Code:06770-3465
Practice Address - Country:US
Practice Address - Phone:203-525-6919
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-12-14
Last Update Date:2015-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT6413367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered