Provider Demographics
NPI:1306355698
Name:KIM, SANDRA YU (FNP, RN, PHN)
Entity Type:Individual
Prefix:
First Name:SANDRA
Middle Name:YU
Last Name:KIM
Suffix:
Gender:F
Credentials:FNP, RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3801 KATELLA AVE STE 330
Mailing Address - Street 2:
Mailing Address - City:LOS ALAMITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90720-6900
Mailing Address - Country:US
Mailing Address - Phone:562-594-9546
Mailing Address - Fax:
Practice Address - Street 1:3801 KATELLA AVE STE 330
Practice Address - Street 2:
Practice Address - City:LOS ALAMITOS
Practice Address - State:CA
Practice Address - Zip Code:90720-6900
Practice Address - Country:US
Practice Address - Phone:562-594-9546
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-09-29
Last Update Date:2021-09-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95018326363LF0000X
CA95107459163WC0400X, 163WM0705X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0400XNursing Service ProvidersRegistered NurseCase Management
No163WM0705XNursing Service ProvidersRegistered NurseMedical-Surgical