Provider Demographics
NPI:1003347253
Name:SONG, JIYOUN
Entity Type:Individual
Prefix:
First Name:JIYOUN
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:15408 NORTHERN BLVD
Mailing Address - Street 2:#2K
Mailing Address - City:FLUSHING
Mailing Address - State:NY
Mailing Address - Zip Code:11354-5040
Mailing Address - Country:US
Mailing Address - Phone:718-445-0200
Mailing Address - Fax:
Practice Address - Street 1:15408 NORTHERN BLVD
Practice Address - Street 2:#2K
Practice Address - City:FLUSHING
Practice Address - State:NY
Practice Address - Zip Code:11354-5040
Practice Address - Country:US
Practice Address - Phone:718-445-0200
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-03-21
Last Update Date:2017-03-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY694059163W00000X
NY431104363LA2100X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2100XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAcute Care
No163W00000XNursing Service ProvidersRegistered Nurse