Provider Demographics
NPI:1356066773
Name:WILLIAMS-LEE, KRISTINA
Entity type:Individual
Prefix:MS
First Name:KRISTINA
Middle Name:
Last Name:WILLIAMS-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 1:115 TUXEDO ST
Mailing Address - Street 2:
Mailing Address - City:HIGHLAND PARK
Mailing Address - State:MI
Mailing Address - Zip Code:48203-3544
Mailing Address - Country:US
Mailing Address - Phone:313-403-8123
Mailing Address - Fax:
Practice Address - Street 1:115 TUXEDO ST
Practice Address - Street 2:
Practice Address - City:HIGHLAND PARK
Practice Address - State:MI
Practice Address - Zip Code:48203-3544
Practice Address - Country:US
Practice Address - Phone:313-403-8123
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-10-07
Last Update Date:2022-10-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MIT520478009305172A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes172A00000XOther Service ProvidersDriver