Provider Demographics
NPI:1588483283
Name:LEE, AMANDA
Entity type:Individual
Prefix:
First Name:AMANDA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3722 NW HUNTSBORO ST APT 101
Mailing Address - Street 2:
Mailing Address - City:LAKE CITY
Mailing Address - State:FL
Mailing Address - Zip Code:32055-8707
Mailing Address - Country:US
Mailing Address - Phone:386-361-1215
Mailing Address - Fax:
Practice Address - Street 1:3722 NW HUNTSBORO ST APT 101
Practice Address - Street 2:
Practice Address - City:LAKE CITY
Practice Address - State:FL
Practice Address - Zip Code:32055-8707
Practice Address - Country:US
Practice Address - Phone:386-361-1215
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-09
Last Update Date:2024-10-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL100974225700000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225700000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersMassage Therapist