Provider Demographics
NPI:1326300534
Name:KIM, GRACE Y (LPN)
Entity Type:Individual
Prefix:MRS
First Name:GRACE
Middle Name:Y
Last Name:KIM
Suffix:
Gender:F
Credentials:LPN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10850 N ORIOLE LN
Mailing Address - Street 2:
Mailing Address - City:MEQUON
Mailing Address - State:WI
Mailing Address - Zip Code:53092-4912
Mailing Address - Country:US
Mailing Address - Phone:262-442-0754
Mailing Address - Fax:800-319-4979
Practice Address - Street 1:10850 N ORIOLE LN
Practice Address - Street 2:
Practice Address - City:MEQUON
Practice Address - State:WI
Practice Address - Zip Code:53092-4912
Practice Address - Country:US
Practice Address - Phone:262-442-0754
Practice Address - Fax:800-319-4979
Is Sole Proprietor?:Yes
Enumeration Date:2012-06-13
Last Update Date:2012-06-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
WI314375-031164W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164W00000XNursing Service ProvidersLicensed Practical Nurse