MEDICARE: MS. JONGMI LEE NP-C, AGPCNP-BC

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	577428	NY
2	363LA2200X	Adult Health Nurse Practitioner	307088	NY
3	363LF0000X	Family Nurse Practitioner	342923	NY

General Provider Information

NPI Number	:	1689996621
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MS. JONGMI LEE NP-C, AGPCNP-BC

Provider Business Mailing Address
First Line	:	2623 SEDGWICK AVE
Second Line	:	4D
City	:	BRONX
State	:	NY
Zip	:	10468-3839
Country	:	US
Telephone Number	:	929-352-0454
Fax Number	:	929-352-0455

Provider Business Practice Location Address
First Line	:	2623 SEDGWICK AVE
Second Line	:	4D
City	:	BRONX
State	:	NY
Zip	:	10468-3839
Country	:	US
Telephone Number	:	929-352-0454
Fax Number	:	929-352-0455

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

Provider Enumeration Date	:	02/18/2010
Last Update Date	:	12/20/2019

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