MEDICARE: ANGELA KIM NP

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	363LF0000X	Family Nurse Practitioner	95009617	CA

Other Identifiers

#	Provider Identifier	Provider Identifier Type	Provider Identifier State	Provider Identifier Issuer
1	95009617	OTHER	CA	NURSE PRACTITIONER FURNISHING
2	95009617	OTHER	CA	NURSE PRACTITIONER
3	95052723	OTHER	CA	REGISTERED NURSE

General Provider Information

NPI Number	:	1619450491
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	ANGELA KIM NP

Provider Business Mailing Address
First Line	:	1930 S BEVERLY GLEN BLVD APT 203
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-5158
Country	:	US
Telephone Number	:	213-925-5254
Fax Number	:

Provider Business Practice Location Address
First Line	:	1930 S BEVERLY GLEN BLVD APT 203
Second Line	:
City	:	LOS ANGELES
State	:	CA
Zip	:	90025-5158
Country	:	US
Telephone Number	:	213-925-5254
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	09/07/2018
Last Update Date	:	09/07/2018

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