Provider Demographics
NPI:1982342432
Name:LEE, SERRA JONGHAE (NP)
Entity Type:Individual
Prefix:
First Name:SERRA
Middle Name:JONGHAE
Last Name:LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:14111 VAN NESS AVE # 5
Mailing Address - Street 2:
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90249-2950
Mailing Address - Country:US
Mailing Address - Phone:142-439-6341
Mailing Address - Fax:424-396-3427
Practice Address - Street 1:14111 VAN NESS AVE # 5
Practice Address - Street 2:
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90249-2950
Practice Address - Country:US
Practice Address - Phone:142-439-6341
Practice Address - Fax:424-396-3427
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-24
Last Update Date:2024-05-07
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95018002363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontologyGroup - Single Specialty