Healthcare Provider Details

I. General information

NPI: 1104621457
Provider Name (Legal Business Name): BRYANNA J LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 02/19/2025
Last Update Date: 10/11/2026
Certification Date: 10/11/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

6873 FASHION HILLS BLVD
SAN DIEGO CA
92111-7653
US

IV. Provider business mailing address

1633 N EDGEMONT ST APT 417
LOS ANGELES CA
90027-6611
US

V. Phone/Fax

Practice location:
  • Phone: 213-308-4408
  • Fax:
Mailing address:
  • Phone: 213-308-4408
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code208D00000X
TaxonomyGeneral Practice Physician
License Number22067
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: