Provider Demographics
NPI:1700232675
Name:KIM, ELLY JINOK
Entity Type:Individual
Prefix:
First Name:ELLY
Middle Name:JINOK
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 1:260 EAST 188TH STREET
Mailing Address - Street 2:
Mailing Address - City:BRONX
Mailing Address - State:NY
Mailing Address - Zip Code:10458-3817
Mailing Address - Country:US
Mailing Address - Phone:718-618-8365
Mailing Address - Fax:
Practice Address - Street 1:260 EAST 188TH STREET
Practice Address - Street 2:
Practice Address - City:BRONX
Practice Address - State:NY
Practice Address - Zip Code:10458-3817
Practice Address - Country:US
Practice Address - Phone:718-618-8365
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2016-05-10
Last Update Date:2016-10-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF340386-1363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily