Provider Demographics
NPI:1215292693
Name:LEE-FARRISH, JEONG
Entity type:Individual
Prefix:
First Name:JEONG
Middle Name:
Last Name:LEE-FARRISH
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 1:114 PALMER RD
Mailing Address - Street 2:
Mailing Address - City:WESTFORD
Mailing Address - State:NY
Mailing Address - Zip Code:13488
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:114 PALMER RD
Practice Address - Street 2:
Practice Address - City:WESTFORD
Practice Address - State:NY
Practice Address - Zip Code:13488-0143
Practice Address - Country:US
Practice Address - Phone:718-309-7024
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-07-11
Last Update Date:2012-07-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY803074174400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist