Provider Demographics
NPI:1548526973
Name:LEE, VIVIAN SUSAN (MD)
Entity type:Individual
Prefix:
First Name:VIVIAN
Middle Name:SUSAN
Last Name:LEE
Suffix:
Gender:F
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:PO BOX 1247
Mailing Address - Street 2:MS 1322-2-EFM
Mailing Address - City:PUYALLUP
Mailing Address - State:WA
Mailing Address - Zip Code:98371-0192
Mailing Address - Country:US
Mailing Address - Phone:253-697-5757
Mailing Address - Fax:253-697-1439
Practice Address - Street 1:1322 3RD ST SE
Practice Address - Street 2:SUITE 240
Practice Address - City:PUYALLUP
Practice Address - State:WA
Practice Address - Zip Code:98372-3771
Practice Address - Country:US
Practice Address - Phone:253-697-5757
Practice Address - Fax:253-697-1439
Is Sole Proprietor?:No
Enumeration Date:2012-04-10
Last Update Date:2016-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
WAMD60573973207Q00000X, 207P00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207Q00000XAllopathic & Osteopathic PhysiciansFamily Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
No207P00000XAllopathic & Osteopathic PhysiciansEmergency Medicine