Basic Information
| Provider Information | |||||||||
| NPI: | 1982295242 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | NATALYA | ||||||||
| MiddleName: | ANTOINETTE | ||||||||
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| Mailing Information | |||||||||
| Address1: | 111 N LOUISE ST UNIT 308 | ||||||||
| Address2: | |||||||||
| City: | GLENDALE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 912064721 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6092512096 | ||||||||
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| Practice Location | |||||||||
| Address1: | 8142 SUNLAND BLVD | ||||||||
| Address2: | |||||||||
| City: | SUN VALLEY | ||||||||
| State: | CA | ||||||||
| PostalCode: | 91352 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 8185828832 | ||||||||
| FaxNumber: | 8185828836 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 01/29/2021 | ||||||||
| LastUpdateDate: | 01/29/2021 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 01/13/2021 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 106S00000X | Y |
No ID Information.