Healthcare Provider Details

I. General information

NPI: 1356228225
Provider Name (Legal Business Name): MICHELLE TERESA KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/20/2025
Last Update Date: 10/17/2025
Certification Date: 10/17/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1173 FRONT ST
SAN DIEGO CA
92101
US

IV. Provider business mailing address

9915 MIRA MESA BLVD STE 220
SAN DIEGO CA
92131-7002
US

V. Phone/Fax

Practice location:
  • Phone: 619-610-1647
  • Fax:
Mailing address:
  • Phone: 858-644-7016
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberNP9535397
License Number StateCA
# 2
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number95286882
License Number StateCA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: