Provider Demographics
NPI:1801671490
Name:LEE, MYONGJA
Entity type:Individual
Prefix:
First Name:MYONGJA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:311 ALLAIRE AVE
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-1802
Mailing Address - Country:US
Mailing Address - Phone:609-481-0347
Mailing Address - Fax:
Practice Address - Street 1:311 ALLAIRE AVE
Practice Address - Street 2:
Practice Address - City:LEONIA
Practice Address - State:NJ
Practice Address - Zip Code:07605-1802
Practice Address - Country:US
Practice Address - Phone:609-481-0347
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-08-30
Last Update Date:2023-08-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ14909500363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily