Provider Demographics
NPI:1992560304
Name:KIM, CHANG SOOK (FNP)
Entity type:Individual
Prefix:
First Name:CHANG SOOK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11825 CAMPUS PARK DR
Mailing Address - Street 2:
Mailing Address - City:BAKERSFIELD
Mailing Address - State:CA
Mailing Address - Zip Code:93311-8656
Mailing Address - Country:US
Mailing Address - Phone:661-490-1249
Mailing Address - Fax:
Practice Address - Street 1:912 FREMONT ST
Practice Address - Street 2:
Practice Address - City:DELANO
Practice Address - State:CA
Practice Address - Zip Code:93215-2713
Practice Address - Country:US
Practice Address - Phone:866-707-6664
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-15
Last Update Date:2024-10-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP95031133363LF0000X
CA95177417163WN0300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WN0300XNursing Service ProvidersRegistered NurseNephrology