Provider Demographics
NPI:1720673544
Name:LEE, KANGWEON (FNP-BC)
Entity Type:Individual
Prefix:
First Name:KANGWEON
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:FNP-BC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:63 MORAINE ST UNIT 23
Mailing Address - Street 2:
Mailing Address - City:BELMONT
Mailing Address - State:MA
Mailing Address - Zip Code:02478-5056
Mailing Address - Country:US
Mailing Address - Phone:219-851-2625
Mailing Address - Fax:
Practice Address - Street 1:63 MORAINE ST UNIT 23
Practice Address - Street 2:
Practice Address - City:BELMONT
Practice Address - State:MA
Practice Address - Zip Code:02478-5056
Practice Address - Country:US
Practice Address - Phone:219-851-2625
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-03
Last Update Date:2023-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2340947163W00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse