Provider Demographics
NPI:1386918456
Name:SHIN, KELLY KA-YOUNG (RN)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:KA-YOUNG
Last Name:SHIN
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 1:16720 S DALTON AVE
Mailing Address - Street 2:APT 1
Mailing Address - City:GARDENA
Mailing Address - State:CA
Mailing Address - Zip Code:90247-5423
Mailing Address - Country:US
Mailing Address - Phone:213-507-2432
Mailing Address - Fax:
Practice Address - Street 1:16720 S DALTON AVE
Practice Address - Street 2:APT 1
Practice Address - City:GARDENA
Practice Address - State:CA
Practice Address - Zip Code:90247-5423
Practice Address - Country:US
Practice Address - Phone:213-507-2432
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2012-03-06
Last Update Date:2012-03-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA793884163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse