Provider Demographics
NPI:1356746028
Name:LEE, JAESUK (FNP-C)
Entity type:Individual
Prefix:
First Name:JAESUK
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1325 SATELLITE BLVD NW BLDG 700
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-4651
Mailing Address - Country:US
Mailing Address - Phone:678-417-1255
Mailing Address - Fax:678-417-1258
Practice Address - Street 1:1325 SATELLITE BLVD NW BLDG 700
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-4651
Practice Address - Country:US
Practice Address - Phone:678-417-1255
Practice Address - Fax:678-417-1258
Is Sole Proprietor?:No
Enumeration Date:2014-10-23
Last Update Date:2015-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY634175163W00000X
GARN244828363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse