Healthcare Provider Details

I. General information

NPI: 1194378539
Provider Name (Legal Business Name): MELISSA JENKINS LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/23/2019
Last Update Date: 04/14/2022
Certification Date: 04/14/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

282 WASHINGTON ST
HARTFORD CT
06106-3322
US

IV. Provider business mailing address

228 E BASS LN
SUFFIELD CT
06078-1956
US

V. Phone/Fax

Practice location:
  • Phone: 860-836-5416
  • Fax:
Mailing address:
  • Phone: 860-836-5416
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License Number8747
License Number StateCT
# 2
Primary TaxonomyN
Taxonomy Code163WP0200X
TaxonomyPediatric Registered Nurse
License Number124342
License Number StateCT

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: