MEDICARE: MRS. MANDI KIANNE LEE MS, CDCA, ATC

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	2255A2300X	Athletic Trainer	36001073A	IN

General Provider Information

NPI Number	:	1942362967
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. MANDI KIANNE LEE MS, CDCA, ATC

Provider Business Mailing Address
First Line	:	335 EATON LEWISBURG RD APT C
Second Line	:
City	:	EATON
State	:	OH
Zip	:	45320-1155
Country	:	US
Telephone Number	:	937-336-4373
Fax Number	:

Provider Business Practice Location Address
First Line	:	515 DAYTON ST
Second Line	:
City	:	HAMILTON
State	:	OH
Zip	:	45011-3455
Country	:	US
Telephone Number	:	513-896-3477
Fax Number	:

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

Provider Enumeration Date	:	12/15/2006
Last Update Date	:	12/20/2022

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