Healthcare Provider Details

I. General information

NPI: 1912089244
Provider Name (Legal Business Name): KELLY H. C. KIM NP
Entity Type: Individual
Gender: Female
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 10/19/2006
Last Update Date: 07/08/2007
Certification Date:
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1708 OLD DONATION PKWY
VIRGINIA BEACH VA
23454-3064
US

IV. Provider business mailing address

5700 CLEVELAND ST SUITE 228
VIRGINIA BEACH VA
23462-1752
US

V. Phone/Fax

Practice location:
  • Phone: 757-395-5300
  • Fax:
Mailing address:
  • Phone: 757-499-2825
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363L00000X
TaxonomyNurse Practitioner
License Number0001199919
License Number StateVA

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: