Healthcare Provider Details

I. General information

NPI: 1760711774
Provider Name (Legal Business Name): JUNGYUNG KO NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

Provider Other Name: LISA KO AGNP

II. Dates (important events)

Enumeration Date: 12/22/2009
Last Update Date: 07/18/2018
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1365 CLIFTON RD NE
ATLANTA GA
30322
US

IV. Provider business mailing address

3211 BRIARCLIFF GABLES CIR NE
ATLANTA GA
30329-2446
US

V. Phone/Fax

Practice location:
  • Phone: 404-778-7777
  • Fax: 404-367-3558
Mailing address:
  • Phone: 954-643-3603
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberSP010618
License Number StatePA
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number0990839
License Number StateCO
# 3
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License Number185605
License Number StateGA
# 4
Primary TaxonomyN
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License Number185605
License Number StateGA
# 5
Primary TaxonomyN
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number1619883
License Number StateCO
# 6
Primary TaxonomyN
Taxonomy Code208M00000X
TaxonomyHospitalist Physician
License NumberRN185605
License Number StateGA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: