Provider Demographics
NPI:1356228225
Name:KIM, MICHELLE TERESA
Entity type:Individual
Prefix:
First Name:MICHELLE
Middle Name:TERESA
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 1:1173 FRONT ST
Mailing Address - Street 2:
Mailing Address - City:SAN DIEGO
Mailing Address - State:CA
Mailing Address - Zip Code:92101-3904
Mailing Address - Country:US
Mailing Address - Phone:619-610-1647
Mailing Address - Fax:
Practice Address - Street 1:1173 FRONT ST
Practice Address - Street 2:
Practice Address - City:SAN DIEGO
Practice Address - State:CA
Practice Address - Zip Code:92101
Practice Address - Country:US
Practice Address - Phone:619-610-1647
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2025-08-20
Last Update Date:2025-08-23
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP9535397363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health