Provider Demographics
NPI:1992132179
Name:LEE, NIKKI
Entity type:Individual
Prefix:
First Name:NIKKI
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 1:711 JEFFERSON AVE
Mailing Address - Street 2:
Mailing Address - City:MEMPHIS
Mailing Address - State:TN
Mailing Address - Zip Code:38105-5003
Mailing Address - Country:US
Mailing Address - Phone:901-448-6580
Mailing Address - Fax:901-448-4734
Practice Address - Street 1:711 JEFFERSON AVE
Practice Address - Street 2:
Practice Address - City:MEMPHIS
Practice Address - State:TN
Practice Address - Zip Code:38105-5003
Practice Address - Country:US
Practice Address - Phone:901-448-6580
Practice Address - Fax:901-448-4734
Is Sole Proprietor?:Yes
Enumeration Date:2013-10-02
Last Update Date:2013-10-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TN252Y00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes252Y00000XAgenciesEarly Intervention Provider Agency