Healthcare Provider Details

I. General information

NPI: 1992449243
Provider Name (Legal Business Name): KRISTEN S KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 04/22/2022
Last Update Date: 06/10/2026
Certification Date: 06/10/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

5225 CANYON CREST DR BLDG 100
RIVERSIDE CA
92507-6301
US

IV. Provider business mailing address

5225 CANYON CREST DR BLDG 100
RIVERSIDE CA
92507-6301
US

V. Phone/Fax

Practice location:
  • Phone: 909-520-1851
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code390200000X
TaxonomyStudent in an Organized Health Care Education/Training Program
License Number
License Number State
# 2
Primary TaxonomyN
Taxonomy Code2084P0800X
TaxonomyPsychiatry Physician
License NumberA189430
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: