Provider Demographics
NPI:1063469997
Name:KIM, JIN-A (ANP)
Entity Type:Individual
Prefix:
First Name:JIN-A
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:ANP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2500 EXECUTIVE DRIVE
Mailing Address - Street 2:SUITE 104
Mailing Address - City:ST. CHARLES
Mailing Address - State:MO
Mailing Address - Zip Code:63303
Mailing Address - Country:US
Mailing Address - Phone:888-811-4677
Mailing Address - Fax:
Practice Address - Street 1:1325 MANCHESTER RD
Practice Address - Street 2:
Practice Address - City:WHEATON
Practice Address - State:IL
Practice Address - Zip Code:60187-4760
Practice Address - Country:US
Practice Address - Phone:630-668-2500
Practice Address - Fax:
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-05-27
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
IL363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health