Basic Information
| Provider Information | |||||||||
| NPI: | 1962088443 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | CANDACE | ||||||||
| MiddleName: | NICHOLE | ||||||||
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| Credential: | NP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 11600 ROXBURGH PASS | ||||||||
| Address2: | |||||||||
| City: | AUSTIN | ||||||||
| State: | TX | ||||||||
| PostalCode: | 787547002 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5125421733 | ||||||||
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| Practice Location | |||||||||
| Address1: | 1301 WONDER WORLD DR | ||||||||
| Address2: | |||||||||
| City: | SAN MARCOS | ||||||||
| State: | TX | ||||||||
| PostalCode: | 786667533 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 5123538979 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 03/23/2021 | ||||||||
| LastUpdateDate: | 08/25/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 08/09/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363L00000X | 1033102 | TX | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner |
No ID Information.