Healthcare Provider Details

I. General information

NPI: 1972017648
Provider Name (Legal Business Name): SEO YOUNG LEE NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: CAROL LEE NP

II. Dates (important events)

Enumeration Date: 11/16/2017
Last Update Date: 11/10/2020
Certification Date: 10/15/2020
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5730 GLENRIDGE DR STE 200
ATLANTA GA
30328-5579
US

IV. Provider business mailing address

1930 BRANNAN RD
MCDONOUGH GA
30253-4310
US

V. Phone/Fax

Practice location:
  • Phone: 404-252-5206
  • Fax: 404-252-1268
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberSP018057
License Number StatePA
# 2
Primary TaxonomyY
Taxonomy Code363LP0200X
TaxonomyPediatric Nurse Practitioner
License NumberRN298728
License Number StateGA
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN685141
License Number StatePA
# 4
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number26NR18993700
License Number StateNJ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: