Provider Demographics
NPI:1104102755
Name:KIM, KRISTY
Entity type:Individual
Prefix:
First Name:KRISTY
Middle Name:
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 1:7554 197TH ST
Mailing Address - Street 2:2 FL
Mailing Address - City:FRESH MEADOWS
Mailing Address - State:NY
Mailing Address - Zip Code:11366-1817
Mailing Address - Country:US
Mailing Address - Phone:917-574-6303
Mailing Address - Fax:
Practice Address - Street 1:7554 197TH ST
Practice Address - Street 2:2FL
Practice Address - City:FRESH MEADOWS
Practice Address - State:NY
Practice Address - Zip Code:11366-1817
Practice Address - Country:US
Practice Address - Phone:917-574-6303
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-10-27
Last Update Date:2011-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY306965164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse