Provider Demographics
NPI:1982428777
Name:KIM, JAE MIN
Entity type:Individual
Prefix:MS
First Name:JAE
Middle Name:MIN
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 1:37 HIGHLINE TRL
Mailing Address - Street 2:
Mailing Address - City:STAMFORD
Mailing Address - State:CT
Mailing Address - Zip Code:06902-1002
Mailing Address - Country:US
Mailing Address - Phone:347-581-5447
Mailing Address - Fax:
Practice Address - Street 1:37 HIGHLINE TRL
Practice Address - Street 2:
Practice Address - City:STAMFORD
Practice Address - State:CT
Practice Address - Zip Code:06902-1002
Practice Address - Country:US
Practice Address - Phone:347-581-5447
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-08
Last Update Date:2024-11-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT104365163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse