Provider Demographics
NPI:1306201793
Name:KIM, RENA (MPH, BSN, RN)
Entity Type:Individual
Prefix:
First Name:RENA
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MPH, BSN, RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1675 GARDEN OF THE GODS RD
Mailing Address - Street 2:
Mailing Address - City:COLORADO SPRINGS
Mailing Address - State:CO
Mailing Address - Zip Code:80907-9444
Mailing Address - Country:US
Mailing Address - Phone:719-578-3102
Mailing Address - Fax:
Practice Address - Street 1:1675 GARDEN OF THE GODS RD
Practice Address - Street 2:
Practice Address - City:COLORADO SPRINGS
Practice Address - State:CO
Practice Address - Zip Code:80907-9444
Practice Address - Country:US
Practice Address - Phone:719-578-3102
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-12-29
Last Update Date:2015-12-29
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1632183163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse