Provider Demographics
NPI:1043908031
Name:KIM, SO RI (CRNP)
Entity Type:Individual
Prefix:
First Name:SO RI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2112 REDBUD LN
Mailing Address - Street 2:
Mailing Address - City:FURLONG
Mailing Address - State:PA
Mailing Address - Zip Code:18925-1530
Mailing Address - Country:US
Mailing Address - Phone:267-334-3216
Mailing Address - Fax:
Practice Address - Street 1:2630 WOODLAND RD
Practice Address - Street 2:
Practice Address - City:ABINGTON
Practice Address - State:PA
Practice Address - Zip Code:19001-3013
Practice Address - Country:US
Practice Address - Phone:215-884-6776
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2023-04-27
Last Update Date:2023-04-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PASP023201363LG0600X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology