MEDICARE: GLORIA KIM PMHNP-BC, FNP-BC

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	363LF0000X	Family Nurse Practitioner	0024175625	VA
2	363LP0808X	Psychiatric/Mental Health Nurse Practitioner	0024175625	VA

General Provider Information

NPI Number	:	1366956278
Entity Type Code	:	Individual
Provider Name (Legal Business Name)	:	GLORIA KIM PMHNP-BC, FNP-BC

Provider Business Mailing Address
First Line	:	5360 DISCOVERY PARK BLVD
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-2860
Country	:	US
Telephone Number	:
Fax Number	:

Provider Business Practice Location Address
First Line	:	5360 DISCOVERY PARK BLVD
Second Line	:
City	:	WILLIAMSBURG
State	:	VA
Zip	:	23188-2860
Country	:	US
Telephone Number	:	804-374-8112
Fax Number	:

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

Provider Enumeration Date	:	11/30/2017
Last Update Date	:	07/08/2022

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