Provider Demographics
NPI:1588107155
Name:LEE, NICOLE MARIE (ATC)
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:MARIE
Last Name:LEE
Suffix:
Gender:F
Credentials:ATC
Other - Prefix:
Other - First Name:NICOLE
Other - Middle Name:MARIE
Other - Last Name:PFUTZENREUTER
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:9 RANCHO JURUPA PL
Mailing Address - Street 2:
Mailing Address - City:POMONA
Mailing Address - State:CA
Mailing Address - Zip Code:91766-4774
Mailing Address - Country:US
Mailing Address - Phone:909-973-9329
Mailing Address - Fax:
Practice Address - Street 1:6505 REFLECTION DR APT 206
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92124-3108
Practice Address - Country:US
Practice Address - Phone:909-973-9329
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-11-29
Last Update Date:2020-01-19
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA20000231762255A2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes2255A2300XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersSpecialist/TechnologistAthletic Trainer