Healthcare Provider Details

I. General information

NPI: 1134030737
Provider Name (Legal Business Name): STACEY YOON YOUNG KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 09/14/2026
Last Update Date: 09/24/2026
Certification Date: 09/24/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

530 1ST AVE STE 9Q
NEW YORK NY
10016-6402
US

IV. Provider business mailing address

530 1ST AVE STE 9Q
NEW YORK NY
10016-6402
US

V. Phone/Fax

Practice location:
  • Phone: 212-263-7225
  • Fax:
Mailing address:
  • Phone: 212-263-7225
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberF360639-01
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: