Healthcare Provider Details

I. General information

NPI: 1922571710
Provider Name (Legal Business Name): MI-KYONG KIM SHIELDS NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 01/04/2019
Last Update Date: 01/04/2019
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

13634 N 93RD AVE STE 100
PEORIA AZ
85381-4915
US

IV. Provider business mailing address

16273 W. MEADE LANE
GOODYEAR AZ
85338
US

V. Phone/Fax

Practice location:
  • Phone: 623-777-0081
  • Fax:
Mailing address:
  • Phone: 623-910-1761
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License NumberAP11206
License Number StateAZ
# 2
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License NumberAP11206
License Number StateAZ
# 3
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP11206
License Number StateAZ
# 4
Primary TaxonomyN
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License NumberAP11206
License Number StateAZ
# 5
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberAP11206
License Number StateAZ
# 6
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP11206
License Number StateAZ

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: