Provider Demographics
NPI:1033181060
Name:KIM, KYONGSOOK (NP)
Entity Type:Individual
Prefix:
First Name:KYONGSOOK
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:18500 NEW HAMPSHIRE AVE
Mailing Address - Street 2:
Mailing Address - City:ASHTON
Mailing Address - State:MD
Mailing Address - Zip Code:20861-9788
Mailing Address - Country:US
Mailing Address - Phone:240-330-0999
Mailing Address - Fax:
Practice Address - Street 1:1380 SOUTHERN AVE SE
Practice Address - Street 2:
Practice Address - City:WASHINGTON
Practice Address - State:DC
Practice Address - Zip Code:20032-4623
Practice Address - Country:US
Practice Address - Phone:202-279-5880
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2006-02-03
Last Update Date:2023-04-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DCRN962194363LG0600X
MDR151075363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology
Provider Identifiers
StateIdentifier IDID TypeIssuer
MDN54833OtherCDS
DC018733100Medicaid
MDR151075OtherDON