Healthcare Provider Details

I. General information

NPI: 1952717670
Provider Name (Legal Business Name): EUN JEONG LEE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/02/2014
Last Update Date: 07/02/2014
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3104 PONTE MORINO DR STE 110
CAMERON PARK CA
95682-8282
US

IV. Provider business mailing address

11594 BIG FOUR WAY
GOLD RIVER CA
95670-8211
US

V. Phone/Fax

Practice location:
  • Phone: 530-621-7700
  • Fax: 530-621-7713
Mailing address:
  • Phone: 530-510-3314
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberNP95000614
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: