Healthcare Provider Details

I. General information

NPI: 1023507100
Provider Name (Legal Business Name): GHIJUNG KYLIE KIM NP-C
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 05/04/2018
Last Update Date: 04/08/2026
Certification Date: 04/08/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1836B CERRILLOS RD
SANTA FE NM
87505-3576
US

IV. Provider business mailing address

1836B CERRILLOS RD
SANTA FE NM
87505-3576
US

V. Phone/Fax

Practice location:
  • Phone: 505-357-1220
  • Fax: 505-805-7356
Mailing address:
  • Phone: 505-357-1220
  • Fax: 505-805-7356

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LP0808X
TaxonomyPsychiatric/Mental Health Nurse Practitioner
License NumberAP136423
License Number StateTX
# 2
Primary TaxonomyN
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberAP136423
License Number StateTX

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: