Healthcare Provider Details

I. General information

NPI: 1124846381
Provider Name (Legal Business Name): SUSAN H LEE APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/27/2024
Last Update Date: 05/19/2025
Certification Date: 05/19/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

170 PROSPECT AVE STE 1
HACKENSACK NJ
07601-1834
US

IV. Provider business mailing address

552 LAUREL RD
RIDGEWOOD NJ
07450-5217
US

V. Phone/Fax

Practice location:
  • Phone: 551-309-3555
  • Fax:
Mailing address:
  • Phone: 917-623-2141
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number26NJ15122000
License Number StateNJ

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: