Healthcare Provider Details

I. General information

NPI: 1720332000
Provider Name (Legal Business Name): JIN SOOK KIM
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/07/2012
Last Update Date: 07/28/2015
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1 PENN PLZ FRNT 7 SUITE 725
NEW YORK NY
10119-0206
US

IV. Provider business mailing address

1 PENN PLZ FRNT 7 725
NEW YORK NY
10119-0206
US

V. Phone/Fax

Practice location:
  • Phone: 917-993-2279
  • Fax:
Mailing address:
  • Phone: 917-993-2279
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LA2200X
TaxonomyAdult Health Nurse Practitioner
License NumberF306114
License Number StateNY
# 2
Primary TaxonomyN
Taxonomy Code364SG0600X
TaxonomyGerontology Clinical Nurse Specialist
License NumberF340851
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: