Provider Demographics
NPI:1861188948
Name:KIM, YEJIN (AGNP)
Entity type:Individual
Prefix:
First Name:YEJIN
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:AGNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4204 SIX FORKS RD APT 914
Mailing Address - Street 2:
Mailing Address - City:RALEIGH
Mailing Address - State:NC
Mailing Address - Zip Code:27609-6423
Mailing Address - Country:US
Mailing Address - Phone:269-944-6470
Mailing Address - Fax:
Practice Address - Street 1:4420 LAKE BOONE TRL
Practice Address - Street 2:
Practice Address - City:RALEIGH
Practice Address - State:NC
Practice Address - Zip Code:27607-7505
Practice Address - Country:US
Practice Address - Phone:919-784-3542
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-04-12
Last Update Date:2023-12-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NC312559163W00000X
NCAG06230234363L00000X
NC5018482363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology