MEDICARE: MRS. HEIDI LEIGH KIM APN

Medicare Provider Information

Scope of Practice

The following information about the specialty of the provider is available:

#	Taxonomy Code	Taxonomy	License Number	License Number State
1	163W00000X	Registered Nurse	32081	AK
2	363LW0102X	Women's Health Nurse Practitioner	1193	AK
3	363LX0001X	Obstetrics & Gynecology Nurse Practitioner	1193	AK

General Provider Information

NPI Number	:	1184929721
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	MRS. HEIDI LEIGH KIM APN

Provider Business Mailing Address
First Line	:	6416 15TH CT APT A
Second Line	:
City	:	ELMENDORF AFB
State	:	AK
Zip	:	99506-2005
Country	:	US
Telephone Number	:	907-375-1943
Fax Number	:

Provider Business Practice Location Address
First Line	:	1108 E NORTHERN LIGHTS BLVD
Second Line	:
City	:	ANCHORAGE
State	:	AK
Zip	:	99508-4219
Country	:	US
Telephone Number	:	907-349-3054
Fax Number	:

Authorized Official
Title or Position	:
Name	:
Credential	:
Telephone Number	:

Provider Enumeration Date	:	01/12/2011
Last Update Date	:	01/12/2011

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