Healthcare Provider Details

I. General information

NPI: 1104740190
Provider Name (Legal Business Name): YOUNGJIN KWON RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 08/05/2026
Last Update Date: 09/23/2026
Certification Date: 09/23/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

11 W PROSPECT AVE
MOUNT VERNON NY
10550-2017
US

IV. Provider business mailing address

845 N BROADWAY
WHITE PLAINS NY
10603-2403
US

V. Phone/Fax

Practice location:
  • Phone: 914-668-8938
  • Fax:
Mailing address:
  • Phone: 914-761-0600
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License Number701319
License Number StateNY

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: