Healthcare Provider Details

I. General information

NPI: 1134047467
Provider Name (Legal Business Name): ELLIYA KIM
Entity Type: Individual
Gender:
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 07/06/2026
Last Update Date: 07/06/2026
Certification Date: 07/06/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5166 E OLIVE AVE
FRESNO CA
93727-2423
US

IV. Provider business mailing address

1806 BEACON CT NE
TACOMA WA
98422-3469
US

V. Phone/Fax

Practice location:
  • Phone: 877-960-3426
  • Fax:
Mailing address:
  • Phone: 253-326-0089
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberRN61476610
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: