Provider Demographics
NPI:1922887306
Name:KIM, MICHELLE BOGO
Entity Type:Individual
Prefix:
First Name:MICHELLE
Middle Name:BOGO
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 1:3230 STEVE REYNOLDS BLVD
Mailing Address - Street 2:STE 214
Mailing Address - City:DULUTH
Mailing Address - State:GA
Mailing Address - Zip Code:30096-8833
Mailing Address - Country:US
Mailing Address - Phone:470-282-1966
Mailing Address - Fax:888-342-1617
Practice Address - Street 1:3230 STEVE REYNOLDS BLVD STE 214
Practice Address - Street 2:
Practice Address - City:DULUTH
Practice Address - State:GA
Practice Address - Zip Code:30096-8833
Practice Address - Country:US
Practice Address - Phone:470-282-1966
Practice Address - Fax:888-342-1617
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes374U00000XNursing Service Related ProvidersHome Health Aide
Provider Identifiers
StateIdentifier IDID TypeIssuer
GA003282818BMedicaid
GA003282818AMedicaid