Provider Demographics
NPI:1750541215
Name:KIM, IRENE E (NP)
Entity type:Individual
Prefix:DR
First Name:IRENE
Middle Name:E
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:222-15 NORTHERN BLVD
Mailing Address - Street 2:C1
Mailing Address - City:BAYSIDE
Mailing Address - State:NY
Mailing Address - Zip Code:11361-2201
Mailing Address - Country:US
Mailing Address - Phone:718-352-6093
Mailing Address - Fax:
Practice Address - Street 1:22215 NORTHERN BLVD
Practice Address - Street 2:
Practice Address - City:BAYSIDE
Practice Address - State:NY
Practice Address - Zip Code:11361-3678
Practice Address - Country:US
Practice Address - Phone:718-352-6093
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2008-06-09
Last Update Date:2022-07-21
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NYF400787363LP0808X, 363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health