Provider Demographics
NPI:1851131114
Name:LEE, JUNGSOO (NURSE PRACTITIONER)
Entity type:Individual
Prefix:MS
First Name:JUNGSOO
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2031 20TH ST APT D
Mailing Address - Street 2:
Mailing Address - City:SANTA MONICA
Mailing Address - State:CA
Mailing Address - Zip Code:90404-4750
Mailing Address - Country:US
Mailing Address - Phone:310-866-7888
Mailing Address - Fax:
Practice Address - Street 1:3114 W BEVERLY BLVD
Practice Address - Street 2:
Practice Address - City:MONTEBELLO
Practice Address - State:CA
Practice Address - Zip Code:90640-2217
Practice Address - Country:US
Practice Address - Phone:323-726-3868
Practice Address - Fax:323-726-3870
Is Sole Proprietor?:No
Enumeration Date:2024-05-24
Last Update Date:2024-05-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95023879363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care