Individual
JAEWON LEE
Active
Sole proprietor
No
Provider details
NPI number
Gender
Man
Credential
CNP
Contact information
Practice address
1217 BONITA ST, GRANTS, NM 87020-2103
(052) 872-9585
(505) 443-8342
Mailing address
1217 BONITA ST, GRANTS, NM 87020-2103
(052) 872-9585
(505) 443-8342
Taxonomy
Speciality
Code
Description
License number
State
363L00000X
Nurse Practitioner
5905
MN
363LF0000X
Family Nurse Practitioner
Primary
66164
NM
363LF0000X
Family Nurse Practitioner
F07161203
IN
Other
Enumeration date
08/08/2016
Last updated
01/15/2025
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