Healthcare Provider Details

I. General information

NPI: 1174359491
Provider Name (Legal Business Name): KEIANNA LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/12/2024
Last Update Date: 07/27/2026
Certification Date: 07/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1465 30TH ST STE K
SAN DIEGO CA
92154-3497
US

IV. Provider business mailing address

1465 30TH ST STE K
SAN DIEGO CA
92154-3497
US

V. Phone/Fax

Practice location:
  • Phone: 619-428-1000
  • Fax:
Mailing address:
  • Phone: 619-428-1000
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code1041C0700X
TaxonomyClinical Social Worker
License NumberASW140195
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: