Basic Information
| Provider Information | |||||||||
| NPI: | 1013030899 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | SUSIE | ||||||||
| MiddleName: | K | ||||||||
| NamePrefix: | MRS. | ||||||||
| NameSuffix: | |||||||||
| Credential: | RN, NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | PO BOX 512717 | ||||||||
| Address2: | |||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 90048 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104235958 | ||||||||
| FaxNumber: | |||||||||
| Practice Location | |||||||||
| Address1: | 8730 ALDEN DR. | ||||||||
| Address2: | 235 | ||||||||
| City: | LOS ANGELES | ||||||||
| State: | CA | ||||||||
| PostalCode: | 900486101 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3104235958 | ||||||||
| FaxNumber: | 3104230146 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/09/2007 | ||||||||
| LastUpdateDate: | 11/07/2013 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | 410162 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | ML0948274 | 01 | CA | DEA | OTHER | 13264 | 01 | CA | FURNISHING LICENSE | OTHER | 410162 | 01 | CA | RN LICENSE | OTHER |