Healthcare Provider Details

I. General information

NPI: 1821542440
Provider Name (Legal Business Name): VICTORIA LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/11/2016
Last Update Date: 08/11/2016
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

255 E MORTON ST
OLD FORGE PA
18518-1960
US

IV. Provider business mailing address

255 EAST MORTON ST
OLD FORGE PA
18518
US

V. Phone/Fax

Practice location:
  • Phone: 570-457-3009
  • Fax:
Mailing address:
  • Phone: 570-457-3009
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number30862537
License Number StatePA

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: