MEDICARE: NICOLE MARIE LEE ATC

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	2255A2300X	Athletic Trainer	2000023176	CA

General Provider Information

NPI Number	:	1588107155
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	NICOLE MARIE LEE ATC

Provider Business Mailing Address
First Line	:	9 RANCHO JURUPA PL
Second Line	:
City	:	POMONA
State	:	CA
Zip	:	91766-4774
Country	:	US
Telephone Number	:	909-973-9329
Fax Number	:

Provider Business Practice Location Address
First Line	:	6505 REFLECTION DR APT 206
Second Line	:
City	:	SAN DIEGO
State	:	CA
Zip	:	92124-3108
Country	:	US
Telephone Number	:	909-973-9329
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	11/29/2016
Last Update Date	:	01/19/2020

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