Provider Demographics
NPI:1023318151
Name:LEE, GWENDOLYN R (CCNS, APRN)
Entity type:Individual
Prefix:
First Name:GWENDOLYN
Middle Name:R
Last Name:LEE
Suffix:
Gender:F
Credentials:CCNS, APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2361 CYPRESS CIRCLE
Mailing Address - Street 2:
Mailing Address - City:CONWAY
Mailing Address - State:SC
Mailing Address - Zip Code:29526
Mailing Address - Country:US
Mailing Address - Phone:843-347-7291
Mailing Address - Fax:843-347-0139
Practice Address - Street 1:2361 CYPRESS CIRCLE
Practice Address - Street 2:
Practice Address - City:CONWAY
Practice Address - State:SC
Practice Address - Zip Code:29526
Practice Address - Country:US
Practice Address - Phone:843-347-7291
Practice Address - Fax:843-347-0139
Is Sole Proprietor?:No
Enumeration Date:2010-10-22
Last Update Date:2010-10-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC4293364SC0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes364SC0200XPhysician Assistants & Advanced Practice Nursing ProvidersClinical Nurse SpecialistCritical Care Medicine