Provider Demographics
NPI:1205340866
Name:LEE, TINA MARIA
Entity type:Individual
Prefix:
First Name:TINA
Middle Name:MARIA
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 1:604 JAMES AVE
Mailing Address - Street 2:
Mailing Address - City:COLONIAL HEIGHTS
Mailing Address - State:VA
Mailing Address - Zip Code:23834-2812
Mailing Address - Country:US
Mailing Address - Phone:804-722-5889
Mailing Address - Fax:
Practice Address - Street 1:604 JAMES AVE
Practice Address - Street 2:
Practice Address - City:COLONIAL HEIGHTS
Practice Address - State:VA
Practice Address - Zip Code:23834-2812
Practice Address - Country:US
Practice Address - Phone:804-722-5889
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-11-18
Last Update Date:2017-11-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA47-2060180171WH0202X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes171WH0202XOther Service ProvidersContractorHome ModificationsGroup - Single Specialty