Provider Demographics
NPI:1801618640
Name:KIM, MIRIAM (MSN AGPCNP-BC CCRN)
Entity type:Individual
Prefix:
First Name:MIRIAM
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:MSN AGPCNP-BC CCRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:329 CONGERS AVE
Mailing Address - Street 2:
Mailing Address - City:NORTHVALE
Mailing Address - State:NJ
Mailing Address - Zip Code:07647-1607
Mailing Address - Country:US
Mailing Address - Phone:201-266-6621
Mailing Address - Fax:
Practice Address - Street 1:329 CONGERS AVE
Practice Address - Street 2:
Practice Address - City:NORTHVALE
Practice Address - State:NJ
Practice Address - Zip Code:07647-1607
Practice Address - Country:US
Practice Address - Phone:201-266-6621
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-10-31
Last Update Date:2024-10-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NY312043363LA2200X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LA2200XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerAdult Health