Healthcare Provider Details

I. General information

NPI: 1821700592
Provider Name (Legal Business Name): JIN KIM LEE A-GNP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 12/14/2022
Last Update Date: 01/16/2024
Certification Date: 01/16/2024
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11501 PAGE SERVICE DR
SAINT LOUIS MO
63146-3530
US

IV. Provider business mailing address

11501 PAGE SERVICE DR
SAINT LOUIS MO
63146-3530
US

V. Phone/Fax

Practice location:
  • Phone: 314-993-3014
  • Fax: 314-993-2065
Mailing address:
  • Phone: 314-993-3014
  • Fax: 314-993-2065

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LX0106X
TaxonomyOccupational Health Nurse Practitioner
License Number2022040714
License Number StateMO

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: