Provider Demographics
NPI:1942512512
Name:KIM, KYOUNGHAE (APRN)
Entity Type:Individual
Prefix:
First Name:KYOUNGHAE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:263 FARMINGTON AVENUE
Mailing Address - Street 2:
Mailing Address - City:FARMIGNTON
Mailing Address - State:CT
Mailing Address - Zip Code:06030-8082
Mailing Address - Country:US
Mailing Address - Phone:860-679-6600
Mailing Address - Fax:860-679-6604
Practice Address - Street 1:263 FARMINGTON AVENUE
Practice Address - Street 2:
Practice Address - City:FARMIGNTON
Practice Address - State:CT
Practice Address - Zip Code:06030-8082
Practice Address - Country:US
Practice Address - Phone:860-679-6600
Practice Address - Fax:860-679-6604
Is Sole Proprietor?:No
Enumeration Date:2010-07-11
Last Update Date:2019-09-20
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CT006943363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health