Provider Demographics
NPI:1821700592
Name:LEE, JIN KIM (A-GNP-C)
Entity Type:Individual
Prefix:
First Name:JIN
Middle Name:KIM
Last Name:LEE
Suffix:
Gender:F
Credentials:A-GNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:11501 PAGE SERVICE DR
Mailing Address - Street 2:
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63146-3530
Mailing Address - Country:US
Mailing Address - Phone:314-993-3014
Mailing Address - Fax:314-993-2065
Practice Address - Street 1:11501 PAGE SERVICE DR
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63146-3530
Practice Address - Country:US
Practice Address - Phone:314-993-3014
Practice Address - Fax:314-993-2065
Is Sole Proprietor?:No
Enumeration Date:2022-12-14
Last Update Date:2024-01-16
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO2022040714363LX0106X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LX0106XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerOccupational Health
Provider Identifiers
StateIdentifier IDID TypeIssuer
MO2007026654OtherRN LICENSE NUMBER
MO2022040714OtherCNP LICENSE NUMBER