Healthcare Provider Details

I. General information

NPI: 1205647237
Provider Name (Legal Business Name): MINJI KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 01/17/2025
Last Update Date: 06/04/2026
Certification Date: 06/04/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 GUSTAVE L LEVY PL
NEW YORK NY
10029-6504
US

IV. Provider business mailing address

1134 SANSOM ST APT 714
PHILADELPHIA PA
19107-4985
US

V. Phone/Fax

Practice location:
  • Phone: 212-241-6500
  • Fax:
Mailing address:
  • Phone:
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN2344092
License Number StateMA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: