Basic Information
| Provider Information | |||||||||
| NPI: | 1306802178 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | LE | ||||||||
| FirstName: | JULIE | ||||||||
| MiddleName: | M | ||||||||
| NamePrefix: | DR. | ||||||||
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| Credential: | OD | ||||||||
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| Mailing Information | |||||||||
| Address1: | 474 WEST STREET | ||||||||
| Address2: | |||||||||
| City: | KEENE | ||||||||
| State: | NH | ||||||||
| PostalCode: | 03431 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 6033527803 | ||||||||
| FaxNumber: | 6033586711 | ||||||||
| Practice Location | |||||||||
| Address1: | 161 JACKSON ST | ||||||||
| Address2: | |||||||||
| City: | LOWELL | ||||||||
| State: | MA | ||||||||
| PostalCode: | 018522103 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 9789379700 | ||||||||
| FaxNumber: | 9782216205 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/21/2006 | ||||||||
| LastUpdateDate: | 06/14/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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| NPICertificationDate: | 06/14/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 152W00000X | 5117 | MA | Y | Eye and Vision Services Providers | Optometrist | 152W00000X | NH0717 | NH | N | Eye and Vision Services Providers | Optometrist |
ID Information
| ID | Type | State | Issuer | Description | 30351596 | 05 | NH | MEDICAID |