Provider Demographics
NPI:1396482642
Name:KIM, SOON MI (LAC)
Entity type:Individual
Prefix:MS
First Name:SOON
Middle Name:MI
Last Name:KIM
Suffix:
Gender:F
Credentials:LAC
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9703 KINGS CROWN COURT APT. 201
Mailing Address - Street 2:
Mailing Address - City:FAIRFAX
Mailing Address - State:VA
Mailing Address - Zip Code:22031
Mailing Address - Country:US
Mailing Address - Phone:201-844-1667
Mailing Address - Fax:
Practice Address - Street 1:5570 STERRETTE PLACE, STE. 308
Practice Address - Street 2:
Practice Address - City:COLUMBIA
Practice Address - State:MD
Practice Address - Zip Code:21044
Practice Address - Country:US
Practice Address - Phone:201-844-1667
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-05-18
Last Update Date:2022-05-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDU02750171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist