Provider Demographics
NPI:1255867594
Name:KIM, GRACE (NURSE PRACTITIONER)
Entity type:Individual
Prefix:
First Name:GRACE
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:9935 LINDLEY AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHRIDGE
Mailing Address - State:CA
Mailing Address - Zip Code:91325-1044
Mailing Address - Country:US
Mailing Address - Phone:818-648-2355
Mailing Address - Fax:818-700-5690
Practice Address - Street 1:18300 ROSCOE BLVD
Practice Address - Street 2:
Practice Address - City:NORTHRIDGE
Practice Address - State:CA
Practice Address - Zip Code:91328
Practice Address - Country:US
Practice Address - Phone:818-885-8500
Practice Address - Fax:818-700-5690
Is Sole Proprietor?:No
Enumeration Date:2017-05-05
Last Update Date:2017-05-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95006124363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily