Provider Demographics
NPI:1598894545
Name:LEE, JUANITA PERRY (ITFSBA)
Entity type:Individual
Prefix:MRS
First Name:JUANITA
Middle Name:PERRY
Last Name:LEE
Suffix:
Gender:F
Credentials:ITFSBA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:220 N MARION DR
Mailing Address - Street 2:
Mailing Address - City:GOLDSBORO
Mailing Address - State:NC
Mailing Address - Zip Code:27534-7613
Mailing Address - Country:US
Mailing Address - Phone:919-738-6749
Mailing Address - Fax:919-751-3930
Practice Address - Street 1:220 N MARION DR
Practice Address - Street 2:
Practice Address - City:GOLDSBORO
Practice Address - State:NC
Practice Address - Zip Code:27534-7613
Practice Address - Country:US
Practice Address - Phone:919-738-6749
Practice Address - Fax:919-751-3930
Is Sole Proprietor?:Yes
Enumeration Date:2007-03-05
Last Update Date:2007-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes174400000XOther Service ProvidersSpecialist
Provider Identifiers
StateIdentifier IDID TypeIssuer
NC8300634KMedicaid
NC8300634Medicaid