Provider Demographics
NPI:1780051763
Name:LEE, NICOLE STEPHANIE (OD)
Entity type:Individual
Prefix:DR
First Name:NICOLE
Middle Name:STEPHANIE
Last Name:LEE
Suffix:
Gender:F
Credentials:OD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2007 S 1ST ST STE 104
Mailing Address - Street 2:
Mailing Address - City:AUSTIN
Mailing Address - State:TX
Mailing Address - Zip Code:78704-5195
Mailing Address - Country:US
Mailing Address - Phone:512-774-6002
Mailing Address - Fax:512-774-5975
Practice Address - Street 1:2007 S 1ST ST STE 104
Practice Address - Street 2:
Practice Address - City:AUSTIN
Practice Address - State:TX
Practice Address - Zip Code:78704-5195
Practice Address - Country:US
Practice Address - Phone:512-774-6002
Practice Address - Fax:512-774-5975
Is Sole Proprietor?:No
Enumeration Date:2015-08-26
Last Update Date:2023-10-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VIVI61152W00000X
TX10506152W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes152W00000XEye and Vision Services ProvidersOptometrist