Provider Demographics
NPI:1538721998
Name:LEE, EUN JUNG (CAA)
Entity type:Individual
Prefix:MISS
First Name:EUN
Middle Name:JUNG
Last Name:LEE
Suffix:
Gender:F
Credentials:CAA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5671 PEACHTREE DUNWOODY RD STE 610
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30342-5013
Mailing Address - Country:US
Mailing Address - Phone:404-257-8601
Mailing Address - Fax:404-851-1649
Practice Address - Street 1:1133 EAGLES LANDING PKWY
Practice Address - Street 2:
Practice Address - City:STOCKBRIDGE
Practice Address - State:GA
Practice Address - Zip Code:30281-5085
Practice Address - Country:US
Practice Address - Phone:678-604-1053
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-07-05
Last Update Date:2021-10-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
GA9394367H00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367H00000XPhysician Assistants & Advanced Practice Nursing ProvidersAnesthesiologist Assistant
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program