Provider Demographics
NPI:1235656240
Name:PAK, KYNA
Entity Type:Individual
Prefix:
First Name:KYNA
Middle Name:
Last Name:PAK
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 1:111 E 18TH ST APT 337
Mailing Address - Street 2:
Mailing Address - City:NORFOLK
Mailing Address - State:VA
Mailing Address - Zip Code:23517-0050
Mailing Address - Country:US
Mailing Address - Phone:702-539-4145
Mailing Address - Fax:
Practice Address - Street 1:PSC 819
Practice Address - Street 2:
Practice Address - City:FPO
Practice Address - State:SPAIN
Practice Address - Zip Code:09645
Practice Address - Country:ES
Practice Address - Phone:314-727-3408
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2017-08-30
Last Update Date:2022-02-03
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0810006104103TC0700X
Provider Taxonomies
Primary?CodeTypeClassificationSpecializationGroup
Yes103TC0700XBehavioral Health & Social Service ProvidersPsychologistClinicalGroup - Multi-Specialty