Provider Demographics
NPI:1053072355
Name:LEE, KYUNG (PMHNP-BC)
Entity type:Individual
Prefix:
First Name:KYUNG
Middle Name:
Last Name:LEE
Suffix:
Gender:M
Credentials:PMHNP-BC
Other - Prefix:
Other - First Name:KYUNG
Other - Middle Name:BOB
Other - Last Name:LEE
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:PMHNP-BC
Mailing Address - Street 1:18765 SW BOONES FERRY RD SUITES 100, 125, 150, 300, 37
Mailing Address - Street 2:
Mailing Address - City:TUALATIN
Mailing Address - State:OR
Mailing Address - Zip Code:97062
Mailing Address - Country:US
Mailing Address - Phone:503-612-1000
Mailing Address - Fax:
Practice Address - Street 1:18765 SW BOONES FERRY RD SUITES 100, 125, 150, 300, 37
Practice Address - Street 2:
Practice Address - City:TUALITIN
Practice Address - State:OR
Practice Address - Zip Code:97062
Practice Address - Country:US
Practice Address - Phone:503-612-1000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-01-07
Last Update Date:2025-01-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
OR10034397363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental HealthGroup - Single Specialty