Provider Demographics
NPI:1609396258
Name:LEE, SOON-DUCK (NP)
Entity type:Individual
Prefix:
First Name:SOON-DUCK
Middle Name:
Last Name:LEE
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:403 CHARLES PL
Mailing Address - Street 2:
Mailing Address - City:LEONIA
Mailing Address - State:NJ
Mailing Address - Zip Code:07605-1309
Mailing Address - Country:US
Mailing Address - Phone:201-450-2131
Mailing Address - Fax:
Practice Address - Street 1:1963 WILLIAMSBRIDGE RD
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10461-1604
Practice Address - Country:US
Practice Address - Phone:646-530-8447
Practice Address - Fax:718-577-5462
Is Sole Proprietor?:Yes
Enumeration Date:2017-06-25
Last Update Date:2019-12-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY342832363LF0000X
NY522996163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamilyGroup - Multi-Specialty
No163W00000XNursing Service ProvidersRegistered NurseGroup - Multi-Specialty
Provider Identifiers
StateIdentifier IDID TypeIssuer
NY342832OtherNURSE PRACTITIONER IN FAMILY HEALTH