Provider Demographics
NPI:1104118017
Name:KIM, JEONGIM
Entity type:Individual
Prefix:MS
First Name:JEONGIM
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 1:14210 ROOSEVELT AVE
Mailing Address - Street 2:402
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-6046
Mailing Address - Country:US
Mailing Address - Phone:646-509-9755
Mailing Address - Fax:
Practice Address - Street 1:14210 ROOSEVELT AVE
Practice Address - Street 2:402
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-6046
Practice Address - Country:US
Practice Address - Phone:646-509-9755
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2011-05-11
Last Update Date:2011-05-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY638188163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse