Provider Demographics
NPI:1295488484
Name:LEE, KENNETH JOE
Entity type:Individual
Prefix:
First Name:KENNETH
Middle Name:JOE
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 1:9825 N 10800 W
Mailing Address - Street 2:
Mailing Address - City:TREMONTON
Mailing Address - State:UT
Mailing Address - Zip Code:84337-9222
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:9825 N 10800 W
Practice Address - Street 2:
Practice Address - City:TREMONTON
Practice Address - State:UT
Practice Address - Zip Code:84337-9222
Practice Address - Country:US
Practice Address - Phone:888-851-3677
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-01-28
Last Update Date:2022-01-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR43661163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse