Provider Demographics
NPI:1346724655
Name:KIM, KATHLEEN VICK (NP)
Entity Type:Individual
Prefix:
First Name:KATHLEEN
Middle Name:VICK
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:5506 BROADWAY BLVD
Mailing Address - Street 2:
Mailing Address - City:GARLAND
Mailing Address - State:TX
Mailing Address - Zip Code:75043-3639
Mailing Address - Country:US
Mailing Address - Phone:972-303-2400
Mailing Address - Fax:972-303-4343
Practice Address - Street 1:5506 BROADWAY BLVD
Practice Address - Street 2:
Practice Address - City:GARLAND
Practice Address - State:TX
Practice Address - Zip Code:75043-3639
Practice Address - Country:US
Practice Address - Phone:972-303-2400
Practice Address - Fax:972-303-4343
Is Sole Proprietor?:No
Enumeration Date:2018-09-21
Last Update Date:2020-12-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
TXAP138350363LP0200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPediatrics