Provider Demographics
NPI:1669960852
Name:LEE, NICKI ROGERS
Entity type:Individual
Prefix:
First Name:NICKI
Middle Name:ROGERS
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 1:22 E WILT AVE
Mailing Address - Street 2:
Mailing Address - City:EUSTIS
Mailing Address - State:FL
Mailing Address - Zip Code:32726-2936
Mailing Address - Country:US
Mailing Address - Phone:352-589-5113
Mailing Address - Fax:352-589-7320
Practice Address - Street 1:22 E WILT AVE
Practice Address - Street 2:
Practice Address - City:EUSTIS
Practice Address - State:FL
Practice Address - Zip Code:32726-2936
Practice Address - Country:US
Practice Address - Phone:352-589-5113
Practice Address - Fax:352-589-7320
Is Sole Proprietor?:Yes
Enumeration Date:2018-04-24
Last Update Date:2018-04-24
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
343900000X
FL47-4922347343900000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes343900000XTransportation ServicesNon-emergency Medical Transport (VAN)