Provider Demographics
NPI:1144334590
Name:DETIEGE-LEE, WANDA (MD)
Entity type:Individual
Prefix:
First Name:WANDA
Middle Name:
Last Name:DETIEGE-LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:WANDA
Other - Middle Name:
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:MD
Mailing Address - Street 1:150 GILBREATH DR
Mailing Address - Street 2:ONEONTA FAMILY CLINIC
Mailing Address - City:ONEONTA
Mailing Address - State:AL
Mailing Address - Zip Code:35121-2827
Mailing Address - Country:US
Mailing Address - Phone:205-274-3353
Mailing Address - Fax:205-274-3354
Practice Address - Street 1:150 GILBREATH DR
Practice Address - Street 2:ONEONTA FAMILY CLINIC
Practice Address - City:ONEONTA
Practice Address - State:AL
Practice Address - Zip Code:35121-2827
Practice Address - Country:US
Practice Address - Phone:205-274-3353
Practice Address - Fax:205-274-3354
Is Sole Proprietor?:No
Enumeration Date:2006-08-19
Last Update Date:2011-02-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AL00014415207P00000X
AL14415133NN1002X, 208D00000X, 207PH0002X, 207Q00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine
No133NN1002XDietary & Nutritional Service ProvidersNutritionistNutrition, Education
No208D00000XAllopathic & Osteopathic PhysiciansGeneral Practice
No207PH0002XAllopathic & Osteopathic PhysiciansEmergency MedicineHospice and Palliative Medicine