Provider Demographics
NPI:1982894861
Name:LEE, KRISTEN MARIE IAGULLI (MD)
Entity Type:Individual
Prefix:
First Name:KRISTEN
Middle Name:MARIE IAGULLI
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:KRISTEN
Other - Middle Name:M
Other - Last Name:IAGULLI
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:MD
Mailing Address - Street 1:245 N BINKLEY ST STE 103
Mailing Address - Street 2:
Mailing Address - City:SOLDOTNA
Mailing Address - State:AK
Mailing Address - Zip Code:99669-7500
Mailing Address - Country:US
Mailing Address - Phone:907-260-4468
Mailing Address - Fax:907-260-4467
Practice Address - Street 1:245 N BINKLEY ST STE 103
Practice Address - Street 2:
Practice Address - City:SOLDOTNA
Practice Address - State:AK
Practice Address - Zip Code:99669-7500
Practice Address - Country:US
Practice Address - Phone:907-260-4468
Practice Address - Fax:907-260-4467
Is Sole Proprietor?:Yes
Enumeration Date:2007-07-27
Last Update Date:2014-03-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AK7051207Q00000X, 207Q00000X
TN46468207VX0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207VX0000XAllopathic & Osteopathic PhysiciansObstetrics & GynecologyObstetrics
Provider Identifiers
StateIdentifier IDID TypeIssuer
AKMD9804Medicaid