Healthcare Provider Details

I. General information

NPI: 1154106813
Provider Name (Legal Business Name): JONG HOON KIM FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/30/2023
Last Update Date: 05/27/2026
Certification Date: 05/27/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

19214 NORTHERN BLVD # 2D
FLUSHING NY
11358-2955
US

IV. Provider business mailing address

1A LOCUST PL
HUNTINGTON STATION NY
11746-4233
US

V. Phone/Fax

Practice location:
  • Phone: 718-762-3240
  • Fax: 855-770-4386
Mailing address:
  • Phone: 347-971-9019
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF351965
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: