Provider Demographics
NPI:1184197824
Name:MIN, KYOUNGLIM (NP)
Entity Type:Individual
Prefix:
First Name:KYOUNGLIM
Middle Name:
Last Name:MIN
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:21 ENTWISTLE AVE
Mailing Address - Street 2:
Mailing Address - City:NUTLEY
Mailing Address - State:NJ
Mailing Address - Zip Code:07110-3209
Mailing Address - Country:US
Mailing Address - Phone:917-702-1461
Mailing Address - Fax:
Practice Address - Street 1:780 8TH AVE STE 201
Practice Address - Street 2:
Practice Address - City:NEW YORK
Practice Address - State:NY
Practice Address - Zip Code:10036-7000
Practice Address - Country:US
Practice Address - Phone:212-757-0222
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-01-04
Last Update Date:2019-01-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY339616363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
Provider Identifiers
StateIdentifier IDID TypeIssuer
207195527OtherPERMANENT RESIDENT