Provider Demographics
NPI:1659981421
Name:AHN, JAE HYUNG (CNA, RNA)
Entity Type:Individual
Prefix:
First Name:JAE HYUNG
Middle Name:
Last Name:AHN
Suffix:
Gender:M
Credentials:CNA, RNA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3681 CRANFORD AVE APT 22
Mailing Address - Street 2:
Mailing Address - City:RIVERSIDE
Mailing Address - State:CA
Mailing Address - Zip Code:92507-4536
Mailing Address - Country:US
Mailing Address - Phone:215-390-4306
Mailing Address - Fax:
Practice Address - Street 1:5800 W WILSON ST
Practice Address - Street 2:
Practice Address - City:BANNING
Practice Address - State:CA
Practice Address - Zip Code:92220-3042
Practice Address - Country:US
Practice Address - Phone:951-845-1606
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2020-08-05
Last Update Date:2020-08-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA01146584376K00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes376K00000XNursing Service Related ProvidersNurse's Aide