Healthcare Provider Details

I. General information

NPI: 1144118423
Provider Name (Legal Business Name): ELISA CHANMEE KIM CRNP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/25/2025
Last Update Date: 11/18/2025
Certification Date: 11/18/2025
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4420 LAKE BOONE TRL
RALEIGH NC
27607-7505
US

IV. Provider business mailing address

5221 PARAMOUNT PKWY STE 420
MORRISVILLE NC
27560-5491
US

V. Phone/Fax

Practice location:
  • Phone: 919-784-3100
  • Fax:
Mailing address:
  • Phone: 984-974-2705
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363LA2100X
TaxonomyAcute Care Nurse Practitioner
License Number5022473
License Number StateNC
# 2
Primary TaxonomyY
Taxonomy Code363LC0200X
TaxonomyCritical Care Medicine Nurse Practitioner
License Number5022473
License Number StateNC

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: