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: 08/24/2026
Certification Date: 08/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1802 W 4TH ST
WILMINGTON DE
19805-3420
US

IV. Provider business mailing address

1806 BEACON CT NE
TACOMA WA
98422-3469
US

V. Phone/Fax

Practice location:
  • Phone: 302-655-5822
  • 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: