Provider Demographics
NPI:1740348986
Name:KIM, GLORIA S (CRNP)
Entity type:Individual
Prefix:
First Name:GLORIA
Middle Name:S
Last Name:KIM
Suffix:
Gender:F
Credentials:CRNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:200 HYGEIA DR STE 2300
Mailing Address - Street 2:
Mailing Address - City:NEWARK
Mailing Address - State:DE
Mailing Address - Zip Code:19713-2049
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:4735 OGLETOWN STANTON RD STE 1250
Practice Address - Street 2:
Practice Address - City:NEWARK
Practice Address - State:DE
Practice Address - Zip Code:19713
Practice Address - Country:US
Practice Address - Phone:302-623-0200
Practice Address - Fax:302-623-0117
Is Sole Proprietor?:No
Enumeration Date:2006-12-04
Last Update Date:2019-04-17
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
DEL1-0020432163W00000X
DELG-0000396363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse
Provider Identifiers
StateIdentifier IDID TypeIssuer
DE1740348986Medicaid
DE162440OtherMEDICARE GROUP NUMBER
DE081802Medicare Oscar/Certification