Provider Demographics
NPI:1851031249
Name:KIM, SOPHIA
Entity type:Individual
Prefix:
First Name:SOPHIA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3625 BRASELTON HWY STE 202
Mailing Address - Street 2:
Mailing Address - City:DACULA
Mailing Address - State:GA
Mailing Address - Zip Code:30019-4695
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:2895 ZELDA RD
Practice Address - Street 2:
Practice Address - City:MONTGOMERY
Practice Address - State:AL
Practice Address - Zip Code:36106-2697
Practice Address - Country:US
Practice Address - Phone:224-715-1032
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-01
Last Update Date:2025-02-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GAGAA-NP002128363LP0200X
AL1-166923363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics