Primary | Taxonomy Code | Taxonomy Specialty | License Number | License State |
---|---|---|---|---|
Y | 224P00000X | Prosthetist | 211-000190 | IL |
NPI | 1427389634 |
---|---|
Provider Name | Mrs. Kelly Marie Lee |
First Address | Chicago, IL 60611-2654 |
Second Address | Chicago, IL 60611-2654 |
Gender | F |
NPI Entity type | Individual |
Is Sole Proprietor | Yes |
Is Organization Subpart | N/A |
Enumeration Date | 28/01/2010 |
Last Update Date | 28/01/2010 |