MEDICARE: MRS. LAURA NICHOLE LEE FNP-C

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	RN154448	GA

General Provider Information

NPI Number	:	1053309526
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. LAURA NICHOLE LEE FNP-C

Provider Business Mailing Address
First Line	:	1051 BOXWOOD DR
Second Line	:
City	:	BAINBRIDGE
State	:	GA
Zip	:	39819-5102
Country	:	US
Telephone Number	:	229-246-3481
Fax Number	:

Provider Business Practice Location Address
First Line	:	980 4TH ST SE
Second Line	:
City	:	CAIRO
State	:	GA
Zip	:	39828-3064
Country	:	US
Telephone Number	:	229-377-2002
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	10/10/2005
Last Update Date	:	07/08/2007

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