Provider Demographics
NPI:1992018006
Name:LEE, MIKYUNG
Entity Type:Individual
Prefix:
First Name:MIKYUNG
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:MI KYUNG
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:852 HOLMDEL RD
Mailing Address - Street 2:
Mailing Address - City:HOLMDEL
Mailing Address - State:NJ
Mailing Address - Zip Code:07733-1731
Mailing Address - Country:US
Mailing Address - Phone:201-446-6090
Mailing Address - Fax:
Practice Address - Street 1:852 HOLMDEL RD
Practice Address - Street 2:
Practice Address - City:HOLMDEL
Practice Address - State:NJ
Practice Address - Zip Code:07733-1731
Practice Address - Country:US
Practice Address - Phone:201-446-6090
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2010-07-17
Last Update Date:2017-01-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJRI24572183500000X
NJ25MZ001232171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist
No183500000XPharmacy Service ProvidersPharmacist