Provider Demographics
NPI:1154997682
Name:KIM, GWYNETH (FNP)
Entity type:Individual
Prefix:
First Name:GWYNETH
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15638 STARBUCK ST
Mailing Address - Street 2:
Mailing Address - City:WHITTIER
Mailing Address - State:CA
Mailing Address - Zip Code:90603-2320
Mailing Address - Country:US
Mailing Address - Phone:213-505-3186
Mailing Address - Fax:
Practice Address - Street 1:14642 NEWPORT AVE STE 105
Practice Address - Street 2:
Practice Address - City:TUSTIN
Practice Address - State:CA
Practice Address - Zip Code:92780-6058
Practice Address - Country:US
Practice Address - Phone:949-520-4175
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2021-06-03
Last Update Date:2021-08-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95016380363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily