Healthcare Provider Details

I. General information

NPI: 1861109555
Provider Name (Legal Business Name): SAEBOM KIM APRN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 11/01/2022
Last Update Date: 08/18/2026
Certification Date: 08/18/2026
Deactivation Date:
Reactivation Date:

III. Provider practice location address

4550 KRUSE WAY STE 125
LAKE OSWEGO OR
97035-3533
US

IV. Provider business mailing address

4550 KRUSE WAY STE 125
LAKE OSWEGO OR
97035-3533
US

V. Phone/Fax

Practice location:
  • Phone: 503-701-2490
  • Fax: 866-663-5826
Mailing address:
  • Phone: 971-803-8383
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyN
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number11022905
License Number StateFL
# 2
Primary TaxonomyY
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License Number10014088
License Number StateOR
# 3
Primary TaxonomyN
Taxonomy Code363LP2300X
TaxonomyPrimary Care Nurse Practitioner
License NumberAP61683297
License Number StateWA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: