Provider Demographics
NPI:1770362998
Name:KIM, ALICE KISUN (PMHNP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:KISUN
Last Name:KIM
Suffix:
Gender:F
Credentials:PMHNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:2558 TIFFANY PL
Mailing Address - Street 2:
Mailing Address - City:FULLERTON
Mailing Address - State:CA
Mailing Address - Zip Code:92833-1527
Mailing Address - Country:US
Mailing Address - Phone:213-200-3500
Mailing Address - Fax:
Practice Address - Street 1:2558 TIFFANY PL
Practice Address - Street 2:
Practice Address - City:FULLERTON
Practice Address - State:CA
Practice Address - Zip Code:92833-1527
Practice Address - Country:US
Practice Address - Phone:213-200-3500
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-09-26
Last Update Date:2023-09-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95027340363LP0808X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LP0808XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerPsychiatric/Mental Health