MEDICARE: HEATHER ROXANNE LEE CRNA

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	163W00000X	Registered Nurse	744422	CA
2	367500000X	Certified Registered Nurse Anesthetist	4292	CA

General Provider Information

NPI Number	:	1184975302
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HEATHER ROXANNE LEE CRNA

Provider Business Mailing Address
First Line	:	3130 VERA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-3221
Country	:	US
Telephone Number	:	808-295-4763
Fax Number	:

Provider Business Practice Location Address
First Line	:	3130 VERA AVE
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90034-3221
Country	:	US
Telephone Number	:	808-295-4763
Fax Number	:

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

Provider Enumeration Date	:	09/27/2012
Last Update Date	:	10/26/2012

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Directions to “ HEATHER ROXANNE LEE CRNA” Practice Location

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