Provider Demographics
NPI:1316410467
Name:LIM, SO YOUNG (NP)
Entity type:Individual
Prefix:
First Name:SO YOUNG
Middle Name:
Last Name:LIM
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 1:130 CENTRE AVE APT 5B
Mailing Address - Street 2:
Mailing Address - City:NEW ROCHELLE
Mailing Address - State:NY
Mailing Address - Zip Code:10805-2851
Mailing Address - Country:US
Mailing Address - Phone:646-345-2186
Mailing Address - Fax:
Practice Address - Street 1:3501 202ND ST
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-1117
Practice Address - Country:US
Practice Address - Phone:718-454-4356
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2019-01-10
Last Update Date:2020-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF343529363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily