Provider Demographics
NPI:1710368550
Name:KANG, GRACE HA EUN (RN, PHN)
Entity Type:Individual
Prefix:MS
First Name:GRACE
Middle Name:HA EUN
Last Name:KANG
Suffix:
Gender:F
Credentials:RN, PHN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:3851 ROSECRANS ST
Mailing Address - Street 2:SUITE Y15
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92110-3115
Mailing Address - Country:US
Mailing Address - Phone:619-692-8435
Mailing Address - Fax:
Practice Address - Street 1:3851 ROSECRANS ST
Practice Address - Street 2:SUITE Y15
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92110-3115
Practice Address - Country:US
Practice Address - Phone:619-692-8435
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2015-06-17
Last Update Date:2015-06-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA761532163W00000X
CA76626163WC1500X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes163W00000XNursing Service ProvidersRegistered Nurse
No163WC1500XNursing Service ProvidersRegistered NurseCommunity Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
CARN 761532OtherCA BRN
CAPHN 76626OtherCA BRN