Healthcare Provider Details

I. General information

NPI: 1417532276
Provider Name (Legal Business Name): MIKI CHU LAM LEE RN, CDCES
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 03/13/2021
Last Update Date: 04/23/2024
Certification Date: 04/23/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

3900 TELEPORT BLVD UNIT 140063
IRVING TX
75014-0017
US

IV. Provider business mailing address

PO BOX 140063
IRVING TX
75014-0063
US

V. Phone/Fax

Practice location:
  • Phone: 312-933-0671
  • Fax:
Mailing address:
  • Phone: 312-933-0761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number041410077
License Number StateIL
# 2
Primary TaxonomyY
Taxonomy Code163WD0400X
TaxonomyDiabetes Educator Registered Nurse
License Number267957
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: