Provider Demographics
NPI:1356034144
Name:LEE, NICOLLE KAILLA
Entity type:Individual
Prefix:
First Name:NICOLLE
Middle Name:KAILLA
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 1:1022 E JACKSON AVE
Mailing Address - Street 2:
Mailing Address - City:RIVERTON
Mailing Address - State:WY
Mailing Address - Zip Code:82501-3721
Mailing Address - Country:US
Mailing Address - Phone:307-840-1418
Mailing Address - Fax:
Practice Address - Street 1:2255 BRUNTON CT
Practice Address - Street 2:
Practice Address - City:RIVERTON
Practice Address - State:WY
Practice Address - Zip Code:82501-2822
Practice Address - Country:US
Practice Address - Phone:307-840-1418
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-05-30
Last Update Date:2023-05-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171M00000XOther Service ProvidersCase Manager/Care Coordinator