Provider Demographics
NPI:1063135408
Name:KIM, NICOLE J
Entity type:Individual
Prefix:
First Name:NICOLE
Middle Name:J
Last Name:KIM
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 1:1221 AHIAHI ST
Mailing Address - Street 2:
Mailing Address - City:HONOLULU
Mailing Address - State:HI
Mailing Address - Zip Code:96817-2012
Mailing Address - Country:US
Mailing Address - Phone:267-454-3594
Mailing Address - Fax:
Practice Address - Street 1:745 NE 122ND AVE
Practice Address - Street 2:
Practice Address - City:PORTLAND
Practice Address - State:OR
Practice Address - Zip Code:97230-2001
Practice Address - Country:US
Practice Address - Phone:502-252-0241
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-21
Last Update Date:2022-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes225100000XRespiratory, Developmental, Rehabilitative and Restorative Service ProvidersPhysical Therapist