Provider Demographics
NPI:1154863520
Name:KIM, JIYEON (PA)
Entity Type:Individual
Prefix:MRS
First Name:JIYEON
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:PA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Mailing Address - Street 1:3610 PEACHTREE INDUSTRIAL BLVD
Mailing Address - Street 2:SUITE 100
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-4953
Mailing Address - Country:US
Mailing Address - Phone:678-417-0332
Mailing Address - Fax:470-200-2823
Practice Address - Street 1:3610 PEACHTREE INDUSTRIAL BLVD
Practice Address - Street 2:SUITE 100
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-4953
Practice Address - Country:US
Practice Address - Phone:678-417-0332
Practice Address - Fax:470-200-2823
Is Sole Proprietor?:No
Enumeration Date:2016-11-16
Last Update Date:2016-11-16
Deactivation Date:
Deactivation Code:
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Provider Licenses
StateLicense IDTaxonomies
GAF0317639363L00000X, 363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner