Provider Demographics
NPI:1609398155
Name:SONG, MIMI KIM (MSN, CNM)
Entity Type:Individual
Prefix:
First Name:MIMI
Middle Name:KIM
Last Name:SONG
Suffix:
Gender:F
Credentials:MSN, CNM
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2615 STONEHILL DR
Mailing Address - Street 2:
Mailing Address - City:CUMMING
Mailing Address - State:GA
Mailing Address - Zip Code:30041-9305
Mailing Address - Country:US
Mailing Address - Phone:678-793-0089
Mailing Address - Fax:
Practice Address - Street 1:10692 MEDLOCK BRIDGE RD STE 100A
Practice Address - Street 2:
Practice Address - City:JOHNS CREEK
Practice Address - State:GA
Practice Address - Zip Code:30097-8497
Practice Address - Country:US
Practice Address - Phone:404-446-2496
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2017-07-15
Last Update Date:2021-02-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
GARN213220207V00000X, 367A00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes367A00000XPhysician Assistants & Advanced Practice Nursing ProvidersAdvanced Practice Midwife
No207V00000XAllopathic & Osteopathic PhysiciansObstetrics & Gynecology