Provider Demographics
NPI:1063393734
Name:LEE, TANJA LATISHA
Entity type:Individual
Prefix:
First Name:TANJA
Middle Name:LATISHA
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 1:3135 NC HIGHWAY 53 E
Mailing Address - Street 2:
Mailing Address - City:BURGAW
Mailing Address - State:NC
Mailing Address - Zip Code:28425-3846
Mailing Address - Country:US
Mailing Address - Phone:910-317-0274
Mailing Address - Fax:
Practice Address - Street 1:3135 NC HIGHWAY 53 E
Practice Address - Street 2:
Practice Address - City:BURGAW
Practice Address - State:NC
Practice Address - Zip Code:28425-3846
Practice Address - Country:US
Practice Address - Phone:910-317-0274
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-09-10
Last Update Date:2025-09-10
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes335E00000XSuppliersProsthetic/Orthotic Supplier