Healthcare Provider Details

I. General information

NPI: 1174457550
Provider Name (Legal Business Name): HEEJUN KONG
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 06/10/2026
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11645 WILSHIRE BLVD STE 800
LOS ANGELES CA
90025-6811
US

IV. Provider business mailing address

1518 FEDERAL AVE PH 15
LOS ANGELES CA
90025-6373
US

V. Phone/Fax

Practice location:
  • Phone: 424-202-2585
  • Fax:
Mailing address:
  • Phone: 424-202-2585
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License Number95039429
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: