Provider Demographics
NPI:1669603437
Name:LEE, NICOLE EVERETT (OTR/L)
Entity type:Individual
Prefix:MRS
First Name:NICOLE
Middle Name:EVERETT
Last Name:LEE
Suffix:
Gender:F
Credentials:OTR/L
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 5496
Mailing Address - Street 2:
Mailing Address - City:FT OGLETHORPE
Mailing Address - State:GA
Mailing Address - Zip Code:30742-0696
Mailing Address - Country:US
Mailing Address - Phone:423-309-7975
Mailing Address - Fax:423-910-1467
Practice Address - Street 1:65 WHITE ST
Practice Address - Street 2:
Practice Address - City:FT OGLETHORPE
Practice Address - State:GA
Practice Address - Zip Code:30742-3694
Practice Address - Country:US
Practice Address - Phone:423-309-7975
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2009-07-28
Last Update Date:2018-01-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAOT004937225X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225X00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersOccupational Therapist
Provider Identifiers
StateIdentifier IDID TypeIssuer
TN1516981Medicaid
GA350828953AMedicaid