Healthcare Provider Details

I. General information

NPI: 1609508746
Provider Name (Legal Business Name): HANNAH LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/28/2022
Last Update Date: 07/05/2023
Certification Date: 07/05/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3850 S NATIONAL AVE STE 705
SPRINGFIELD MO
65807-5239
US

IV. Provider business mailing address

3850 S NATIONAL AVE STE 705
SPRINGFIELD MO
65807-5239
US

V. Phone/Fax

Practice location:
  • Phone: 417-888-0858
  • Fax: 417-889-0476
Mailing address:
  • Phone: 417-888-0858
  • Fax: 417-889-0476

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code207N00000X
TaxonomyDermatology Physician
License Number2022024350
License Number StateMO
# 2
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number2022024350
License Number StateMO

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: