Provider Demographics
NPI:1255880142
Name:LEE, AMY
Entity type:Individual
Prefix:
First Name:AMY
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 1:5106 BIRCH ST APT 2
Mailing Address - Street 2:
Mailing Address - City:WESTON
Mailing Address - State:WI
Mailing Address - Zip Code:54476-2545
Mailing Address - Country:US
Mailing Address - Phone:715-432-1468
Mailing Address - Fax:
Practice Address - Street 1:5106 BIRCH ST APT 2
Practice Address - Street 2:
Practice Address - City:WESTON
Practice Address - State:WI
Practice Address - Zip Code:54476-2545
Practice Address - Country:US
Practice Address - Phone:715-432-1468
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-10-03
Last Update Date:2016-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI315812-31164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse