Provider Demographics
NPI:1720103427
Name:KIM, KWON SOON YOO (NURSE PRACTIONER)
Entity Type:Individual
Prefix:MRS
First Name:KWON SOON
Middle Name:YOO
Last Name:KIM
Suffix:
Gender:F
Credentials:NURSE PRACTIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:519 S. TOPSIDE PL.
Mailing Address - Street 2:
Mailing Address - City:DIAMOND BAR
Mailing Address - State:CA
Mailing Address - Zip Code:91765-1879
Mailing Address - Country:US
Mailing Address - Phone:626-571-4590
Mailing Address - Fax:626-307-7369
Practice Address - Street 1:1840 S. SAN GABRIEL BLVD,
Practice Address - Street 2:
Practice Address - City:SAN GABRIEL
Practice Address - State:CA
Practice Address - Zip Code:91776-3930
Practice Address - Country:US
Practice Address - Phone:626-571-4590
Practice Address - Fax:626-307-7369
Is Sole Proprietor?:No
Enumeration Date:2007-03-20
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CANP13939363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner