Provider Demographics
NPI:1669109518
Name:LEE, THOMAS (MS RD)
Entity type:Individual
Prefix:
First Name:THOMAS
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:MS RD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:85099 CHRISTIAN WAY APT 114
Mailing Address - Street 2:
Mailing Address - City:YULEE
Mailing Address - State:FL
Mailing Address - Zip Code:32097-3402
Mailing Address - Country:US
Mailing Address - Phone:904-463-2570
Mailing Address - Fax:
Practice Address - Street 1:85099 CHRISTIAN WAY APT 114
Practice Address - Street 2:
Practice Address - City:YULEE
Practice Address - State:FL
Practice Address - Zip Code:32097-3402
Practice Address - Country:US
Practice Address - Phone:904-463-2570
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-08-02
Last Update Date:2022-08-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
86040770133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered