Provider Demographics
NPI:1548754385
Name:KIM, LISA JIYOUNG (FNP-C)
Entity Type:Individual
Prefix:
First Name:LISA
Middle Name:JIYOUNG
Last Name:KIM
Suffix:
Gender:F
Credentials:FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:801 ALBANY STREET
Mailing Address - Street 2:FLOOR GROUND
Mailing Address - City:BOSTON
Mailing Address - State:MA
Mailing Address - Zip Code:02119
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:830 HARRISON AVE
Practice Address - Street 2:MOAKLEY, 3RD FLOOR
Practice Address - City:BOSTON
Practice Address - State:MA
Practice Address - Zip Code:02118
Practice Address - Country:US
Practice Address - Phone:617-638-6428
Practice Address - Fax:617-638-5756
Is Sole Proprietor?:No
Enumeration Date:2018-06-15
Last Update Date:2022-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MARN2278996363LF0000X
390200000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program
Provider Identifiers
StateIdentifier IDID TypeIssuer
MA110146618AMedicaid