Provider Demographics
NPI:1417670290
Name:KIM, JANNIE RENE (APRN)
Entity Type:Individual
Prefix:
First Name:JANNIE
Middle Name:RENE
Last Name:KIM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:JANNIE
Other - Middle Name:RENE
Other - Last Name:SURATOS
Other - Suffix:
Other - Last Name Type:Former Name
Other - Credentials:
Mailing Address - Street 1:7955 TUCKERMAN LN
Mailing Address - Street 2:
Mailing Address - City:ROCKVILLE
Mailing Address - State:MD
Mailing Address - Zip Code:20854-3243
Mailing Address - Country:US
Mailing Address - Phone:478-335-6759
Mailing Address - Fax:
Practice Address - Street 1:7955 TUCKERMAN LN
Practice Address - Street 2:
Practice Address - City:ROCKVILLE
Practice Address - State:MD
Practice Address - Zip Code:20854-3243
Practice Address - Country:US
Practice Address - Phone:866-389-2727
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-09-26
Last Update Date:2022-10-27
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR255370363LP2300X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP2300XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPrimary Care