Provider Demographics
NPI:1124453311
Name:IN, KACY EUNKYUNG (APN)
Entity type:Individual
Prefix:
First Name:KACY
Middle Name:EUNKYUNG
Last Name:IN
Suffix:
Gender:F
Credentials:APN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3 STRATFORD RD
Mailing Address - Street 2:ENGLEWOOD CLIFFS
Mailing Address - City:ENGLEWOOD CLIFFS
Mailing Address - State:NJ
Mailing Address - Zip Code:07632-1925
Mailing Address - Country:US
Mailing Address - Phone:201-944-0670
Mailing Address - Fax:
Practice Address - Street 1:817 RAHWAY AVE
Practice Address - Street 2:ELIZABETH
Practice Address - City:ELIZABETH
Practice Address - State:NJ
Practice Address - Zip Code:07202-2212
Practice Address - Country:US
Practice Address - Phone:908-353-5750
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2013-09-06
Last Update Date:2013-09-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NJ00410200363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily