Healthcare Provider Details

I. General information

NPI: 1023841947
Provider Name (Legal Business Name): ALICE KWON-SONG NP
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/26/2024
Last Update Date: 08/26/2024
Certification Date: 08/26/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

15825 LAGUNA CANYON RD STE 104
IRVINE CA
92618-2126
US

IV. Provider business mailing address

11052 LINDA LN APT B
GARDEN GROVE CA
92840-5216
US

V. Phone/Fax

Practice location:
  • Phone: 949-585-9870
  • Fax:
Mailing address:
  • Phone: 213-800-1947
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number95030728
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: