Basic Information
| Provider Information | |||||||||
| NPI: | 1790246833 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | NICOLE | ||||||||
| MiddleName: | ERICA | ||||||||
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| Credential: | MD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 290 E TOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6147885400 | ||||||||
| FaxNumber: | 6147885500 | ||||||||
| Practice Location | |||||||||
| Address1: | 290 E TOWN ST | ||||||||
| Address2: | |||||||||
| City: | COLUMBUS | ||||||||
| State: | OH | ||||||||
| PostalCode: | 432154602 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6145668270 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 03/29/2019 | ||||||||
| LastUpdateDate: | 06/28/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 06/28/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | OH | Y | Student, Health Care | Student in an Organized Health Care Education/Training Program |
No ID Information.