Healthcare Provider Details

I. General information

NPI: 1235874900
Provider Name (Legal Business Name): MEGHAN LEE
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 04/28/2022
Last Update Date: 04/28/2022
Certification Date: 04/28/2022
Deactivation Date:
Reactivation Date:

III. Provider practice location address

VIA PORDENONE, 52 BUILDING 1462
AVIANO PN
33080
IT

IV. Provider business mailing address

PSC 103 BOX 1371
APO AE
09603-0014
US

V. Phone/Fax

Practice location:
  • Phone: 43-430-9060
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code2255A2300X
TaxonomyAthletic Trainer
License NumberAT003726
License Number StateGA

VII. Legacy identifiers

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

# 1
IdentifierAT003726
Identifier TypeOTHER
Identifier StateGA
Identifier IssuerGEORGIA BOARD OF ATHLETIC TRAINERS

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: