Provider Demographics
NPI:1962776765
Name:KIM, GRACE H (PNP)
Entity type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:H
Last Name:KIM
Suffix:
Gender:F
Credentials:PNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1824 HILLHURST AVE
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90027-4408
Mailing Address - Country:US
Mailing Address - Phone:323-664-1977
Mailing Address - Fax:323-664-0870
Practice Address - Street 1:1824 HILLHURST AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90027-4408
Practice Address - Country:US
Practice Address - Phone:323-664-1977
Practice Address - Fax:323-664-0870
Is Sole Proprietor?:No
Enumeration Date:2012-02-27
Last Update Date:2012-03-22
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA16561363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics