Provider Demographics
NPI:1639776933
Name:IZADI, JEONGSIM KIM (RN)
Entity Type:Individual
Prefix:MRS
First Name:JEONGSIM
Middle Name:KIM
Last Name:IZADI
Suffix:
Gender:F
Credentials:RN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2814 MONTAIR PL
Mailing Address - Street 2:
Mailing Address - City:UNION CITY
Mailing Address - State:CA
Mailing Address - Zip Code:94587-1680
Mailing Address - Country:US
Mailing Address - Phone:510-907-0014
Mailing Address - Fax:
Practice Address - Street 1:2814 MONTAIR PL
Practice Address - Street 2:
Practice Address - City:UNION CITY
Practice Address - State:CA
Practice Address - Zip Code:94587-1680
Practice Address - Country:US
Practice Address - Phone:510-907-0014
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-10-08
Last Update Date:2021-08-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CAD2102705163WH1000X
CA95016945363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163WH1000XNursing Service ProvidersRegistered NurseHospice