Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 156FX1800X | Optician | LDO001865 | GA |
NPI | 1225204522 |
---|---|
Provider Name | Michele Diane Lee |
First Address | Marietta, GA 30066-1097 |
Second Address | Marietta, GA 30066-1097 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 06/05/2008 |
Last Update Date | 06/05/2008 |