Provider Demographics
NPI:1124839162
Name:LEE, MICHELLE M
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:M
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 1:17628 W PERSHING ST
Mailing Address - Street 2:
Mailing Address - City:SURPRISE
Mailing Address - State:AZ
Mailing Address - Zip Code:85388-5022
Mailing Address - Country:US
Mailing Address - Phone:520-686-0253
Mailing Address - Fax:480-718-8628
Practice Address - Street 1:17628 W PERSHING ST
Practice Address - Street 2:
Practice Address - City:SURPRISE
Practice Address - State:AZ
Practice Address - Zip Code:85388-5022
Practice Address - Country:US
Practice Address - Phone:520-686-0253
Practice Address - Fax:480-718-8628
Is Sole Proprietor?:Yes
Enumeration Date:2025-01-17
Last Update Date:2025-01-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
AZAL13059H310400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes310400000XNursing & Custodial Care FacilitiesAssisted Living Facility