=====================================================
General NPI Number Information
=====================================================
NPI Number | 1790035004
-----------------------------------------------------
Entity Type | Individual
-----------------------------------------------------
Provider Name | MOONWHA KANG N.P
-----------------------------------------------------
Gender | Female
-----------------------------------------------------
=====================================================
Dates
=====================================================
Enumeration Date | 09/13/2012
-----------------------------------------------------
Last Update Date | 10/17/2018
-----------------------------------------------------
=====================================================
Provider Practice Location Address
=====================================================
Address Line | 845 PALMER AVE DEPT OF
-----------------------------------------------------
City | MAMARONECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10543
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-864-5857
-----------------------------------------------------
Fax | 914-864-5859
-----------------------------------------------------
=====================================================
Provider Business Mailing Address
=====================================================
Address Line | 845 PALMER AVE DEPT OF
-----------------------------------------------------
City | MAMARONECK
-----------------------------------------------------
State | NY
-----------------------------------------------------
Zip | 10543-2406
-----------------------------------------------------
Country | US
-----------------------------------------------------
Telephone | 914-864-5857
-----------------------------------------------------
Fax | 914-864-5859
-----------------------------------------------------
=====================================================
Authorized Official
=====================================================
Title or Position |
-----------------------------------------------------
Name |
-----------------------------------------------------
Credential |
-----------------------------------------------------
Telephone |
-----------------------------------------------------
=====================================================
Scope of Practice (Provider's specialty)
=====================================================
Taxonomy #1
-----------------------------------------------------
Taxonomy Code | 363LA2200X
-----------------------------------------------------
Taxonomy Name | Adult Health Nurse Practitioner
-----------------------------------------------------
License Number | F305931
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------
Taxonomy #2
-----------------------------------------------------
Taxonomy Code | 363LG0600X
-----------------------------------------------------
Taxonomy Name | Gerontology Nurse Practitioner
-----------------------------------------------------
License Number | F340829
-----------------------------------------------------
License Number State | NY
-----------------------------------------------------