Provider Demographics
NPI:1295254167
Name:LEE, CAMILLA (RD, CDN)
Entity type:Individual
Prefix:
First Name:CAMILLA
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:RD, CDN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:28 SAINT JAMES PL APT 4B
Mailing Address - Street 2:
Mailing Address - City:BROOKLYN
Mailing Address - State:NY
Mailing Address - Zip Code:11205-5013
Mailing Address - Country:US
Mailing Address - Phone:917-328-9869
Mailing Address - Fax:
Practice Address - Street 1:28 SAINT JAMES PL APT 4B
Practice Address - Street 2:
Practice Address - City:BROOKLYN
Practice Address - State:NY
Practice Address - Zip Code:11205-5013
Practice Address - Country:US
Practice Address - Phone:917-328-9869
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-09-12
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY009053-1133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered