Basic Information
| Provider Information | |||||||||
| NPI: | 1639661689 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | KIERSTAN | ||||||||
| MiddleName: | ELIZABETH | ||||||||
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| Credential: | M.A., CF-SLP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 94121 PALM CIR | ||||||||
| Address2: | |||||||||
| City: | FERNANDINA BEACH | ||||||||
| State: | FL | ||||||||
| PostalCode: | 320349472 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9045832108 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1297 WINTER GARDEN VINELAND RD # 112 | ||||||||
| Address2: | |||||||||
| City: | WINTER GARDEN | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347876706 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4079050531 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 06/05/2018 | ||||||||
| LastUpdateDate: | 06/05/2018 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 235Z00000X | SZ8202 | FL | Y | Speech, Language and Hearing Service Providers | Speech-Language Pathologist |
No ID Information.