Basic Information
| Provider Information | |||||||||
| NPI: | 1477894293 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | PENNY | ||||||||
| MiddleName: | LAINE | ||||||||
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| Credential: | FNP-C | ||||||||
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| Mailing Information | |||||||||
| Address1: | 7010 E CHAUNCEY LN STE 225 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850543117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6023685014 | ||||||||
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| Practice Location | |||||||||
| Address1: | 7010 E CHAUNCEY LN STE 225 | ||||||||
| Address2: | |||||||||
| City: | PHOENIX | ||||||||
| State: | AZ | ||||||||
| PostalCode: | 850543117 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4805855200 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/04/2013 | ||||||||
| LastUpdateDate: | 06/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/25/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LF0000X | AP4877 | AZ | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 806811 | 05 | AZ | MEDICAID |