Provider Demographics
NPI:1366153546
Name:LEE, STACIA
Entity type:Individual
Prefix:
First Name:STACIA
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 1:900 LAKE OVERLOOK DR
Mailing Address - Street 2:
Mailing Address - City:BOWIE
Mailing Address - State:MD
Mailing Address - Zip Code:20721-2931
Mailing Address - Country:US
Mailing Address - Phone:240-412-4194
Mailing Address - Fax:
Practice Address - Street 1:900 LAKE OVERLOOK DR
Practice Address - Street 2:
Practice Address - City:BOWIE
Practice Address - State:MD
Practice Address - Zip Code:20721-2931
Practice Address - Country:US
Practice Address - Phone:240-412-4194
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-12-08
Last Update Date:2022-12-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes224P00000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersProsthetist
No171400000XOther Service ProvidersHealth & Wellness Coach