Healthcare Provider Details

I. General information

NPI: 1700766938
Provider Name (Legal Business Name): GRACE STAR RYU FNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/08/2025
Last Update Date: 09/08/2025
Certification Date: 09/07/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

63 CANDLEWOOD WAY
BUENA PARK CA
90621-1005
US

IV. Provider business mailing address

63 CANDLEWOOD WAY
BUENA PARK CA
90621-1005
US

V. Phone/Fax

Practice location:
  • Phone: 310-227-0653
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95036897
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: