Healthcare Provider Details

I. General information

NPI: 1184929721
Provider Name (Legal Business Name): HEIDI LEIGH KIM APN
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/12/2011
Last Update Date: 01/12/2011
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1108 E NORTHERN LIGHTS BLVD
ANCHORAGE AK
99508-4219
US

IV. Provider business mailing address

6416 15TH CT APT A
ELMENDORF AFB AK
99506-2005
US

V. Phone/Fax

Practice location:
  • Phone: 907-349-3054
  • Fax:
Mailing address:
  • Phone: 907-375-1943
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LW0102X
TaxonomyWomen's Health Nurse Practitioner
License Number1193
License Number StateAK
# 2
Primary TaxonomyN
Taxonomy Code363LX0001X
TaxonomyObstetrics & Gynecology Nurse Practitioner
License Number1193
License Number StateAK
# 3
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number32081
License Number StateAK

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: