Provider Demographics
NPI:1760194484
Name:KIM, MI KYONG
Entity Type:Individual
Prefix:
First Name:MI KYONG
Middle Name:
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 1:428 S MARIPOSA AVE APT F
Mailing Address - Street 2:
Mailing Address - City:LOS ANGELES
Mailing Address - State:CA
Mailing Address - Zip Code:90020-2915
Mailing Address - Country:US
Mailing Address - Phone:213-700-6336
Mailing Address - Fax:213-765-0537
Practice Address - Street 1:2829 S GRAND AVE
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90007-3304
Practice Address - Country:US
Practice Address - Phone:213-699-7041
Practice Address - Fax:213-765-0537
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2022-12-14
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA690473164X00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes164X00000XNursing Service ProvidersLicensed Vocational Nurse