Provider Demographics
NPI:1336970052
Name:RHIM, KISUP (FNP)
Entity type:Individual
Prefix:
First Name:KISUP
Middle Name:
Last Name:RHIM
Suffix:
Gender:M
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:165 REED LAND
Mailing Address - Street 2:
Mailing Address - City:LA HABRA
Mailing Address - State:CA
Mailing Address - Zip Code:90631
Mailing Address - Country:US
Mailing Address - Phone:213-503-7769
Mailing Address - Fax:
Practice Address - Street 1:5731 BEACH BLVD
Practice Address - Street 2:ROOM 202
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621
Practice Address - Country:US
Practice Address - Phone:213-503-7769
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-13
Last Update Date:2024-08-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027432363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily