Provider Demographics
NPI:1326802364
Name:KIM, MICHELLE (NP)
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:
Last Name:KIM
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 1:12900 PARK PLAZA DR STE 150
Mailing Address - Street 2:
Mailing Address - City:CERRITOS
Mailing Address - State:CA
Mailing Address - Zip Code:90703-9329
Mailing Address - Country:US
Mailing Address - Phone:866-646-3553
Mailing Address - Fax:
Practice Address - Street 1:12900 PARK PLAZA DR STE 150
Practice Address - Street 2:
Practice Address - City:CERRITOS
Practice Address - State:CA
Practice Address - Zip Code:90703-9329
Practice Address - Country:US
Practice Address - Phone:866-646-3553
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2024-02-09
Last Update Date:2024-02-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027599363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner