Provider Demographics
NPI:1700517422
Name:LEE, STEPHANIE (PA)
Entity Type:Individual
Prefix:
First Name:STEPHANIE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:PA
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 159
Mailing Address - Street 2:
Mailing Address - City:WINGATE
Mailing Address - State:NC
Mailing Address - Zip Code:28174-0159
Mailing Address - Country:US
Mailing Address - Phone:704-233-8051
Mailing Address - Fax:
Practice Address - Street 1:800 ROSE ST FL 2
Practice Address - Street 2:
Practice Address - City:LEXINGTON
Practice Address - State:KY
Practice Address - Zip Code:40536-8274
Practice Address - Country:US
Practice Address - Phone:859-562-1085
Practice Address - Fax:859-257-5152
Is Sole Proprietor?:Yes
Enumeration Date:2022-06-22
Last Update Date:2023-10-25
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
KYTC394363A00000X, 363AM0700X, 363AS0400X
KYPA3225363AM0700X, 363AS0400X, 363A00000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant
No363AM0700XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantMedical
No363AS0400XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician AssistantSurgical
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program