Provider Demographics
NPI:1992584775
Name:KIM, YEONJU
Entity type:Individual
Prefix:
First Name:YEONJU
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:OLIVIA
Other - Middle Name:
Other - Last Name:KIM
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:
Mailing Address - Street 1:1 W PALISADES BLVD APT B22
Mailing Address - Street 2:
Mailing Address - City:PALISADES PARK
Mailing Address - State:NJ
Mailing Address - Zip Code:07650-2827
Mailing Address - Country:US
Mailing Address - Phone:201-575-1369
Mailing Address - Fax:
Practice Address - Street 1:1 W PALISADES BLVD APT B22
Practice Address - Street 2:
Practice Address - City:PALISADES PARK
Practice Address - State:NJ
Practice Address - Zip Code:07650-2827
Practice Address - Country:US
Practice Address - Phone:201-575-1369
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-21
Last Update Date:2023-09-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ26NR25373100163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse