Provider Demographics
NPI:1124708003
Name:LEE, KAILEY
Entity type:Individual
Prefix:
First Name:KAILEY
Middle Name:
Last Name:LEE
Suffix:
Gender:
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1117 J1 WOODRUFF RD
Mailing Address - Street 2:STE 41
Mailing Address - City:GREENVILLE
Mailing Address - State:SC
Mailing Address - Zip Code:29607
Mailing Address - Country:US
Mailing Address - Phone:864-777-9868
Mailing Address - Fax:
Practice Address - Street 1:1117 J1 WOODRUFF ROAD
Practice Address - Street 2:STE 41
Practice Address - City:GREENVILLE
Practice Address - State:SC
Practice Address - Zip Code:29607
Practice Address - Country:US
Practice Address - Phone:626-238-8628
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-07-24
Last Update Date:2025-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
SC27876363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGroup - Single Specialty