Provider Demographics
NPI:1801968649
Name:LEE, LAUREL (CNM MSN NP)
Entity type:Individual
Prefix:MS
First Name:LAUREL
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:CNM MSN NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:240 NE 139TH AVE
Mailing Address - Street 2:
Mailing Address - City:PORTLAND
Mailing Address - State:OR
Mailing Address - Zip Code:97230
Mailing Address - Country:US
Mailing Address - Phone:503-775-1957
Mailing Address - Fax:
Practice Address - Street 1:3231 SE 50TH AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97206
Practice Address - Country:US
Practice Address - Phone:503-775-1957
Practice Address - Fax:503-788-7289
Is Sole Proprietor?:No
Enumeration Date:2006-11-15
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR084051307N5363L00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Not Answered367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
Provider Identifiers
StateIdentifier IDID TypeIssuer
R85415Medicare UPIN
0000111978Medicare ID - Type Unspecified