Provider Demographics
NPI:1881271294
Name:LEE, CONNIE JO
Entity type:Individual
Prefix:
First Name:CONNIE
Middle Name:JO
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 1:3211 MCCORKINDALE RD
Mailing Address - Street 2:
Mailing Address - City:CALEDONIA
Mailing Address - State:NY
Mailing Address - Zip Code:14423-9773
Mailing Address - Country:US
Mailing Address - Phone:585-314-6444
Mailing Address - Fax:
Practice Address - Street 1:1000 ELMWOOD AVE STE 100
Practice Address - Street 2:
Practice Address - City:ROCHESTER
Practice Address - State:NY
Practice Address - Zip Code:14620-3093
Practice Address - Country:US
Practice Address - Phone:585-271-2897
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2021-03-24
Last Update Date:2021-03-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY380004163WG0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163WG0000XNursing Service ProvidersRegistered NurseGeneral Practice