Basic Information
| Provider Information | |||||||||
| NPI: | 1265855027 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | AMANDA | ||||||||
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| Mailing Information | |||||||||
| Address1: | 196 THOMAS JOHNSON DR | ||||||||
| Address2: | SUITE 215 | ||||||||
| City: | FREDERICK | ||||||||
| State: | MD | ||||||||
| PostalCode: | 217024397 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016689988 | ||||||||
| FaxNumber: | 3016689977 | ||||||||
| Practice Location | |||||||||
| Address1: | 3581 OLD WASHINGTON RD | ||||||||
| Address2: | SUITE F | ||||||||
| City: | WALDORF | ||||||||
| State: | MD | ||||||||
| PostalCode: | 206023270 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3016384400 | ||||||||
| FaxNumber: | 3016382200 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/30/2014 | ||||||||
| LastUpdateDate: | 01/30/2014 | ||||||||
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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 | 363L00000X | R192568 | MD | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.