Provider Demographics
NPI:1790582377
Name:LEE, TIMOTHY
Entity type:Individual
Prefix:
First Name:TIMOTHY
Middle Name:
Last Name:LEE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:6110 MANDERSON ST
Mailing Address - Street 2:
Mailing Address - City:OMAHA
Mailing Address - State:NE
Mailing Address - Zip Code:68104-2643
Mailing Address - Country:US
Mailing Address - Phone:531-495-2567
Mailing Address - Fax:
Practice Address - Street 1:4816 S 24TH ST
Practice Address - Street 2:
Practice Address - City:OMAHA
Practice Address - State:NE
Practice Address - Zip Code:68107-2703
Practice Address - Country:US
Practice Address - Phone:402-320-5578
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2025-02-28
Last Update Date:2025-02-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes3747P1801XNursing Service Related ProvidersTechnicianPersonal Care Attendant