Provider Demographics
NPI:1184192627
Name:KIM, LYDIA K
Entity Type:Individual
Prefix:
First Name:LYDIA
Middle Name:K
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:450 PINTAIL CT
Mailing Address - Street 2:
Mailing Address - City:SUWANEE
Mailing Address - State:GA
Mailing Address - Zip Code:30024-6072
Mailing Address - Country:US
Mailing Address - Phone:770-825-3380
Mailing Address - Fax:470-709-2794
Practice Address - Street 1:450 PINTAIL CT
Practice Address - Street 2:
Practice Address - City:SUWANEE
Practice Address - State:GA
Practice Address - Zip Code:30024-6072
Practice Address - Country:US
Practice Address - Phone:770-825-3380
Practice Address - Fax:470-709-2794
Is Sole Proprietor?:Yes
Enumeration Date:2018-11-02
Last Update Date:2018-11-02
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GA067-R-1643374U00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes374U00000XNursing Service Related ProvidersHome Health AideGroup - Single Specialty