Provider Demographics
NPI:1568756229
Name:KIM, JEONG MI (RN, CRNA)
Entity Type:Individual
Prefix:
First Name:JEONG MI
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:RN, CRNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:475 LINDEN LN
Mailing Address - Street 2:APT 406
Mailing Address - City:MEDIA
Mailing Address - State:PA
Mailing Address - Zip Code:19063-3670
Mailing Address - Country:US
Mailing Address - Phone:818-523-7390
Mailing Address - Fax:
Practice Address - Street 1:11234 ANDERSON ST
Practice Address - Street 2:
Practice Address - City:LOMA LINDA
Practice Address - State:CA
Practice Address - Zip Code:92354-2804
Practice Address - Country:US
Practice Address - Phone:866-436-2098
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2011-05-30
Last Update Date:2021-12-06
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY5349730163W00000X
PARN596280163W00000X
PA88733367500000X
CA660703163W00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No367500000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Anesthetist, Certified Registered