Provider Demographics
NPI:1104174085
Name:LEE, JOHNNIE LEGRANT
Entity type:Individual
Prefix:MR
First Name:JOHNNIE
Middle Name:LEGRANT
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 1:4347 4TH AVE S
Mailing Address - Street 2:
Mailing Address - City:MINNEAPOLIS
Mailing Address - State:MN
Mailing Address - Zip Code:55409-2115
Mailing Address - Country:US
Mailing Address - Phone:612-823-3880
Mailing Address - Fax:
Practice Address - Street 1:4347 4TH AVE S
Practice Address - Street 2:
Practice Address - City:MINNEAPOLIS
Practice Address - State:MN
Practice Address - Zip Code:55409-2115
Practice Address - Country:US
Practice Address - Phone:612-823-3880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2012-08-26
Last Update Date:2012-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN270227392311ZA0620X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes311ZA0620XNursing & Custodial Care FacilitiesCustodial Care FacilityAdult Care Home