Healthcare Provider Details

I. General information

NPI: 1669315099
Provider Name (Legal Business Name): SOPHIE JIAE LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/10/2026
Last Update Date: 04/10/2026
Certification Date: 04/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1080 MARINA VILLAGE PKWY
ALAMEDA CA
94501-6427
US

IV. Provider business mailing address

6911 SAN JOAQUIN CIR
BUENA PARK CA
90620-2951
US

V. Phone/Fax

Practice location:
  • Phone: 510-418-5094
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: