Basic Information
| Provider Information | |||||||||
| NPI: | 1518063478 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | MAYRE | ||||||||
| MiddleName: | TAMARA | ||||||||
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| Credential: | PMHNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 3835 N FREEWAY BLVD STE 100 | ||||||||
| Address2: | |||||||||
| City: | SACRAMENTO | ||||||||
| State: | CA | ||||||||
| PostalCode: | 958341954 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9165767900 | ||||||||
| FaxNumber: | 9162850338 | ||||||||
| Practice Location | |||||||||
| Address1: | 770 MASON ST STE 120 | ||||||||
| Address2: | |||||||||
| City: | VACAVILLE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 956884648 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7077413037 | ||||||||
| FaxNumber: | 7074512324 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 09/16/2006 | ||||||||
| LastUpdateDate: | 03/29/2018 | ||||||||
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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 | 363LP0808X | 10571 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Psych/Mental Health |
ID Information
| ID | Type | State | Issuer | Description | 10571 | 01 | CA | NP LICENSE NUMBER | OTHER |