Provider Demographics
NPI:1316662133
Name:LEE, NICOLE
Entity type:Individual
Prefix:
First Name:NICOLE
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 1:5505 PEACHTREE DUNWOODY RD STE 600
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-1717
Mailing Address - Country:US
Mailing Address - Phone:404-355-0743
Mailing Address - Fax:
Practice Address - Street 1:5505 PEACHTREE DUNWOODY RD STE 600
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30342-1717
Practice Address - Country:US
Practice Address - Phone:404-355-0743
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-10-04
Last Update Date:2024-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA12199363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant