Provider Demographics
NPI:1104243195
Name:LEE, MARCIE (NP-C)
Entity type:Individual
Prefix:
First Name:MARCIE
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:51 BROOKS RD
Mailing Address - Street 2:
Mailing Address - City:HATTIESBURG
Mailing Address - State:MS
Mailing Address - Zip Code:39401-8927
Mailing Address - Country:US
Mailing Address - Phone:601-528-2680
Mailing Address - Fax:443-662-4230
Practice Address - Street 1:51 BROOKS RD
Practice Address - Street 2:
Practice Address - City:HATTIESBURG
Practice Address - State:MS
Practice Address - Zip Code:39401-8927
Practice Address - Country:US
Practice Address - Phone:601-528-2680
Practice Address - Fax:443-662-4230
Is Sole Proprietor?:No
Enumeration Date:2014-03-27
Last Update Date:2014-03-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MSR834138363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner