MEDICARE: DR. RYAN LEE

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	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	2022007521	MO
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	209019766	IL

General Provider Information

NPI Number	:	1154708832
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	DR. RYAN LEE

Provider Business Mailing Address
First Line	:	2500 W BRADLEY PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4716
Country	:	US
Telephone Number	:	773-739-5422
Fax Number	:	773-409-8585

Provider Business Practice Location Address
First Line	:	2500 W BRADLEY PL
Second Line	:
City	:	CHICAGO
State	:	IL
Zip	:	60618-4716
Country	:	US
Telephone Number	:	773-739-5422
Fax Number	:	773-409-8585

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

Provider Enumeration Date	:	05/01/2015
Last Update Date	:	08/07/2023

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Directions to “ DR. RYAN LEE ” Practice Location

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