=====================================================
General NPI Number Information
=====================================================
NPI Number | 1760291082
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | CHANDELLE LEE
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 01/01/2025
-----------------------------------------------------
Last Update Date | 01/01/2025
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 6921 E GARTH CIR # B
-----------------------------------------------------
City | PALMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99645-5922
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-745-5444
-----------------------------------------------------
Fax | 907-745-3774
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | PO BOX 2353
-----------------------------------------------------
City | PALMER
-----------------------------------------------------
State | AK
-----------------------------------------------------
Zip | 99645-2353
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 907-795-0515
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 225700000X
-----------------------------------------------------
Taxonomy Name | Massage Therapist
-----------------------------------------------------
License Number | 102111
-----------------------------------------------------
License Number State | AK
-----------------------------------------------------