Provider Demographics
NPI:1265051320
Name:LIM, KELLY YOUNGAE (NP-C)
Entity type:Individual
Prefix:
First Name:KELLY
Middle Name:YOUNGAE
Last Name:LIM
Suffix:
Gender:F
Credentials:NP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2614 CYPRESS POINT DR
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-2062
Mailing Address - Country:US
Mailing Address - Phone:714-310-8525
Mailing Address - Fax:
Practice Address - Street 1:3663 W 6TH ST STE 103
Practice Address - Street 2:
Practice Address - City:LOS ANGELES
Practice Address - State:CA
Practice Address - Zip Code:90020-3047
Practice Address - Country:US
Practice Address - Phone:213-306-2221
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2020-04-09
Last Update Date:2020-04-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95014062363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily