Healthcare Provider Details

I. General information

NPI: 1518456474
Provider Name (Legal Business Name): MI KYEONG JUNG RN
Entity Type: Individual
Gender: Female
Sole Proprietor: Y

II. Dates (important events)

Enumeration Date: 05/07/2018
Last Update Date: 08/23/2023
Certification Date: 08/23/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

RAF LAKENHEATH HOSPITAL
BRANDON SUFFOLK
IP27 9PN
GB

IV. Provider business mailing address

243 S 45TH ST UNIT 7
PHILADELPHIA PA
19104-2950
US

V. Phone/Fax

Practice location:
  • Phone: 314-226-8762
  • Fax:
Mailing address:
  • Phone: 253-754-1575
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code163W00000X
TaxonomyRegistered Nurse
License NumberR233058
License Number StateMD

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: