=====================================================
General NPI Number Information
=====================================================
NPI Number | 1548919004
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | YANA KIM
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 03/22/2022
-----------------------------------------------------
Last Update Date | 03/22/2022
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 3301 MATLOCK RD
-----------------------------------------------------
City | ARLINGTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 76015-2908
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 682-509-6200
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 1432 MEADOW VISTA DR
-----------------------------------------------------
City | CARROLLTON
-----------------------------------------------------
State | TX
-----------------------------------------------------
Zip | 75007-6047
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 702-985-7789
-----------------------------------------------------
Fax |
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2100X
-----------------------------------------------------
Taxonomy Name | Acute Care Nurse Practitioner
-----------------------------------------------------
License Number | 1073115
-----------------------------------------------------
License Number State | TX
-----------------------------------------------------