Provider Demographics
NPI:1659974780
Name:KIM, CHRISTINA J
Entity Type:Individual
Prefix:
First Name:CHRISTINA
Middle Name:J
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:37 LENOX AVE
Mailing Address - Street 2:
Mailing Address - City:DEMAREST
Mailing Address - State:NJ
Mailing Address - Zip Code:07627
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:230 E RIDGEWOOD AVE
Practice Address - Street 2:
Practice Address - City:PARAMUS
Practice Address - State:NJ
Practice Address - Zip Code:07652-4142
Practice Address - Country:US
Practice Address - Phone:201-967-4000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-11-20
Last Update Date:2020-11-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NJ86112546133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes133V00000XDietary & Nutritional Service ProvidersDietitian, Registered