Provider Demographics
NPI:1386119378
Name:KIM, JEA A (RN)
Entity type:Individual
Prefix:MRS
First Name:JEA
Middle Name:A
Last Name:KIM
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:17 FIFTH AVE APT 63
Mailing Address - Street 2:
Mailing Address - City:PELHAM
Mailing Address - State:NY
Mailing Address - Zip Code:10803-1561
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:17 FIFTH AVE APT 63
Practice Address - Street 2:
Practice Address - City:PELHAM
Practice Address - State:NY
Practice Address - Zip Code:10803-1561
Practice Address - Country:US
Practice Address - Phone:917-519-3794
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2018-10-05
Last Update Date:2018-10-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY540472163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse