Healthcare Provider Details

I. General information

NPI: 1790306744
Provider Name (Legal Business Name): KORINNE LEE FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/30/2020
Last Update Date: 03/07/2024
Certification Date: 03/07/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

14780 W MOUNTAIN VIEW BLVD STE 120
SURPRISE AZ
85374-7280
US

IV. Provider business mailing address

14200 W CELEBRATE LIFE WAY
GOODYEAR AZ
85338-3007
US

V. Phone/Fax

Practice location:
  • Phone: 623-215-9460
  • Fax: 623-282-3576
Mailing address:
  • Phone: 623-466-4073
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number240576
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code207Q00000X
TaxonomyFamily Medicine Physician
License Number240576
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: