MEDICARE: CAMILLA LEE RD, CDN

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	133V00000X	Registered Dietitian	009053-1	NY

General Provider Information

NPI Number	:	1295254167
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	CAMILLA LEE RD, CDN

Provider Business Mailing Address
First Line	:	28 SAINT JAMES PL APT 4B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11205-5013
Country	:	US
Telephone Number	:	917-328-9869
Fax Number	:

Provider Business Practice Location Address
First Line	:	28 SAINT JAMES PL APT 4B
Second Line	:
City	:	BROOKLYN
State	:	NY
Zip	:	11205-5013
Country	:	US
Telephone Number	:	917-328-9869
Fax Number	:

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

Provider Enumeration Date	:	09/12/2017
Last Update Date	:	07/21/2022

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