Provider Demographics
NPI:1740823244
Name:EGILSON LEE, BRIELLE (DC)
Entity type:Individual
Prefix:DR
First Name:BRIELLE
Middle Name:
Last Name:EGILSON LEE
Suffix:
Gender:F
Credentials:DC
Other - Prefix:
Other - First Name:BRIELLE
Other - Middle Name:
Other - Last Name:EGILSON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:PO BOX 68
Mailing Address - Street 2:
Mailing Address - City:LAKEVILLE
Mailing Address - State:MN
Mailing Address - Zip Code:55044-0068
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:20772 HOLYOKE AVE
Practice Address - Street 2:
Practice Address - City:LAKEVILLE
Practice Address - State:MN
Practice Address - Zip Code:55044-9824
Practice Address - Country:US
Practice Address - Phone:952-232-1935
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-10-28
Last Update Date:2019-10-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MN6650111N00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes111N00000XChiropractic ProvidersChiropractor