Provider Demographics
NPI:1316965981
Name:LEE, CAROL M (CRNA)
Entity type:Individual
Prefix:
First Name:CAROL
Middle Name:M
Last Name:LEE
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1027 WASHINGTON AVE
Mailing Address - Street 2:
Mailing Address - City:DETROIT LAKES
Mailing Address - State:MN
Mailing Address - Zip Code:56501-3409
Mailing Address - Country:US
Mailing Address - Phone:218-847-5611
Mailing Address - Fax:218-847-0881
Practice Address - Street 1:1027 WASHINGTON AVE
Practice Address - Street 2:
Practice Address - City:DETROIT LAKES
Practice Address - State:MN
Practice Address - Zip Code:56501
Practice Address - Country:US
Practice Address - Phone:218-847-5611
Practice Address - Fax:218-847-0881
Is Sole Proprietor?:No
Enumeration Date:2006-07-18
Last Update Date:2018-09-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NDR20470367500000X
MNR 134622-6367500000X
MNCRNA 0373367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
N/AMedicare UPIN