Provider Demographics
NPI:1801267919
Name:LEE, CONNIE
Entity type:Individual
Prefix:
First Name:CONNIE
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 1:9396D BALTIMORE NATIONAL PIKE
Mailing Address - Street 2:
Mailing Address - City:ELLICOTT CITY
Mailing Address - State:MD
Mailing Address - Zip Code:21042-2802
Mailing Address - Country:US
Mailing Address - Phone:410-480-9110
Mailing Address - Fax:
Practice Address - Street 1:9396D BALTIMORE NATIONAL PIKE
Practice Address - Street 2:
Practice Address - City:ELLICOTT CITY
Practice Address - State:MD
Practice Address - Zip Code:21042-2802
Practice Address - Country:US
Practice Address - Phone:410-480-9110
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-10-15
Last Update Date:2019-01-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDC05908363A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363A00000XPhysician Assistants & Advanced Practice Nursing ProvidersPhysician Assistant