Healthcare Provider Details

I. General information

NPI: 1144697913
Provider Name (Legal Business Name): HEA-YOUNG KIM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 08/28/2015
Last Update Date: 08/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

123 SUMMER ST SAINT VINCENT HOSPITAL
WORCESTER MA
01608-1216
US

IV. Provider business mailing address

200 NICKERSON RD SUITE #110
MARLBOROUGH MA
01752-4635
US

V. Phone/Fax

Practice location:
  • Phone: 774-279-9947
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberRN2282062
License Number StateMA
# 2
Primary TaxonomyY
Taxonomy Code363LG0600X
TaxonomyGerontology Nurse Practitioner
License NumberRN2282062
License Number StateMA

VII. Legacy identifiers

For crosswalk purposes, the following legacy (non-NPI) identifiers are available for this provider:

# 1
IdentifierRN2282062
Identifier TypeOTHER
Identifier StateMA
Identifier IssuerAPRN

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: