MEDICARE: HOLLY 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	163W00000X	Registered Nurse	R186583-3	MN

General Provider Information

NPI Number	:	1306163019
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	HOLLY LEE

Provider Business Mailing Address
First Line	:	1324 PAYNE AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-3434
Country	:	US
Telephone Number	:	651-793-6901
Fax Number	:

Provider Business Practice Location Address
First Line	:	1324 PAYNE AVE
Second Line	:
City	:	SAINT PAUL
State	:	MN
Zip	:	55130-3434
Country	:	US
Telephone Number	:	651-793-6901
Fax Number	:

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

Provider Enumeration Date	:	04/21/2010
Last Update Date	:	04/21/2010

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Directions to “ HOLLY LEE ” Practice Location

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