Provider Demographics
NPI:1215307095
Name:KIM, JUNG O (NP)
Entity type:Individual
Prefix:
First Name:JUNG
Middle Name:O
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1600 W AVENUE J
Mailing Address - Street 2:
Mailing Address - City:LANCASTER
Mailing Address - State:CA
Mailing Address - Zip Code:93534-2814
Mailing Address - Country:US
Mailing Address - Phone:661-478-7420
Mailing Address - Fax:661-726-6149
Practice Address - Street 1:1600 W AVENUE J
Practice Address - Street 2:
Practice Address - City:LANCASTER
Practice Address - State:CA
Practice Address - Zip Code:93534-2814
Practice Address - Country:US
Practice Address - Phone:661-478-7420
Practice Address - Fax:661-726-6149
Is Sole Proprietor?:No
Enumeration Date:2015-10-06
Last Update Date:2022-08-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95002596363LP2300X, 363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care
No363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily