Basic Information
| Provider Information | |||||||||
| NPI: | 1164022448 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LEE | ||||||||
| FirstName: | KWANG YEON CAROL | ||||||||
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| Mailing Information | |||||||||
| Address1: | 2119 WINTERWOOD DR | ||||||||
| Address2: | |||||||||
| City: | FULLERTON | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928331251 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3106944318 | ||||||||
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| Practice Location | |||||||||
| Address1: | 101 THE CITY DR S | ||||||||
| Address2: | |||||||||
| City: | ORANGE | ||||||||
| State: | CA | ||||||||
| PostalCode: | 928683298 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 7148807812 | ||||||||
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| Other Information | |||||||||
| ProviderEnumerationDate: | 10/27/2020 | ||||||||
| LastUpdateDate: | 10/27/2020 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 10/27/2020 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 363LA2100X | 95015771 | CA | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Acute Care |
No ID Information.