Provider Demographics
NPI:1053649590
Name:KIM, GINNA J (CRNA)
Entity Type:Individual
Prefix:
First Name:GINNA
Middle Name:J
Last Name:KIM
Suffix:
Gender:F
Credentials:CRNA
Other - Prefix:
Other - First Name:GINNA
Other - Middle Name:J
Other - Last Name:MOON
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:CRNA
Mailing Address - Street 1:105 WILLOW PKWY
Mailing Address - Street 2:
Mailing Address - City:BUFFALO GROVE
Mailing Address - State:IL
Mailing Address - Zip Code:60089-6608
Mailing Address - Country:US
Mailing Address - Phone:847-567-3123
Mailing Address - Fax:
Practice Address - Street 1:801 S MILWAUKEE AVE
Practice Address - Street 2:
Practice Address - City:LIBERTYVILLE
Practice Address - State:IL
Practice Address - Zip Code:60048-3204
Practice Address - Country:US
Practice Address - Phone:847-362-2905
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2009-11-20
Last Update Date:2014-01-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL041329165163W00000X
IL209007882367500000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered
No163W00000XNursing Service ProvidersRegistered Nurse