1376213215 NPI number — REBECCA LEE CPNP-PC

Table of content: REBECCA LEE CPNP-PC (NPI 1376213215)

General

This information contains only most important part of the NPI data, for complete information, including NPI referencing materials please refer to 1376213215 NPI number — REBECCA LEE CPNP-PC

Organization/Personal Information

Employer Identification Number (EIN):
Provider Organization Name:
Provider Last Name:
LEE
Provider First Name:
REBECCA
Provider Middle Name:
Provider Name Prefix Text:
Provider Name Suffix Text:
Provider Credential Text:
CPNP-PC
Provider Gender Code:
F

Provider's Other Name Information

Provider Other Organization Name:
Provider Other Organization Name Type Code:
Provider Other Last Name:
Provider Other First Name:
Provider Other Middle Name:
Provider Other Name Prefix Text:
Provider Other Name Suffix Text:
Provider Other Credential Text:
Provider Other Last Name Type Code:

NPI Number Information

NPI Number:
1376213215
Entity Type Code:
Individual
Replacement NPI:
Last Update Date:
04/05/2024
NPI Deactivation Reason Code:
NPI Deactivation Date:
NPI Reactivation Date:

Provider's Business Mailing Address

Provider First Line Business Mailing Address:
4196 W US HIGHWAY 90 STE 105
Provider Second Line Business Mailing Address:
Provider Business Mailing Address City Name:
LAKE CITY
Provider Business Mailing Address State Name:
FL
Provider Business Mailing Address Postal Code:
32055-8834
Provider Business Mailing Address Country Code:
US
Provider Business Mailing Address Telephone Number:
386-243-8474
Provider Business Mailing Address Fax Number:
386-438-5945

Provider's Practice Location Mailing Address

Provider First Line Business Practice Location Address:
4196 W US HIGHWAY 90 STE 105
Provider Second Line Business Practice Location Address:
Provider Business Practice Location Address City Name:
LAKE CITY
Provider Business Practice Location Address State Name:
FL
Provider Business Practice Location Address Postal Code:
32055-8834
Provider Business Practice Location Address Country Code:
US
Provider Business Practice Location Address Telephone Number:
386-243-8474
Provider Business Practice Location Address Fax Number:
386-438-5945
Provider Enumeration Date:
09/13/2021

Additional Information

			
		

Authorized Official

Authorized Official Last Name:
Authorized Official First Name:
Authorized Official Middle Name:
Authorized Official Title or Position:
Authorized Official Telephone Number:

Provider Taxonomy Codes

  • Taxonomy code: 163WP0200X , with the licence number:  RN9410116 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 163WP0218X , with the licence number: RN9410116 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .
  • Taxonomy code: 363LP0200X , with the licence number: APRN11029330 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "Y" .
  • Taxonomy code: 163W00000X , with the licence number: RN9410116 , registered in the state of FL ; information, associated with the NPI states the following Primary Taxonomy Switch: "N" .

Other Provider's Identifiers (legacy, non-NPI)

  • Identifier: 120144800 . This is a "Florida Medicaid Provider ID" identifier , issued by the state of ( FL ) . This identifiers is of the category "MEDICAID".