Provider Demographics
NPI:1760711774
Name:KO, JUNGYUNG (NP)
Entity Type:Individual
Prefix:MISS
First Name:JUNGYUNG
Middle Name:
Last Name:KO
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:LISA
Other - Middle Name:
Other - Last Name:KO
Other - Suffix:
Other - Last Name Type:Other Name
Other - Credentials:AGNP
Mailing Address - Street 1:3211 BRIARCLIFF GABLES CIR NE
Mailing Address - Street 2:
Mailing Address - City:ATLANTA
Mailing Address - State:GA
Mailing Address - Zip Code:30329-2446
Mailing Address - Country:US
Mailing Address - Phone:954-643-3603
Mailing Address - Fax:
Practice Address - Street 1:1365 CLIFTON RD NE
Practice Address - Street 2:
Practice Address - City:ATLANTA
Practice Address - State:GA
Practice Address - Zip Code:30322
Practice Address - Country:US
Practice Address - Phone:404-778-7777
Practice Address - Fax:404-367-3558
Is Sole Proprietor?:No
Enumeration Date:2009-12-22
Last Update Date:2018-07-18
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CO1619883163W00000X
GARN185605208M00000X
PASP010618363LA2200X
CO0990839363LA2200X
GA185605363LG0600X, 363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health
No163W00000XNursing Service ProvidersRegistered Nurse
No208M00000XAllopathic & Osteopathic PhysiciansHospitalist
No363LG0600XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerGerontology