Provider Demographics
NPI:1831148469
Name:KIM-SHEPHERD, SO YOUN (FNP)
Entity type:Individual
Prefix:MS
First Name:SO YOUN
Middle Name:
Last Name:KIM-SHEPHERD
Suffix:
Gender:F
Credentials:FNP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:660 S EUCLID AVE
Mailing Address - Street 2:C B 8072
Mailing Address - City:SAINT LOUIS
Mailing Address - State:MO
Mailing Address - Zip Code:63110-1010
Mailing Address - Country:US
Mailing Address - Phone:314-362-9123
Mailing Address - Fax:314-747-3338
Practice Address - Street 1:400 S KINGSHIGHWAY BLVD
Practice Address - Street 2:
Practice Address - City:SAINT LOUIS
Practice Address - State:MO
Practice Address - Zip Code:63110-1014
Practice Address - Country:US
Practice Address - Phone:314-362-9123
Practice Address - Fax:314-747-3338
Is Sole Proprietor?:No
Enumeration Date:2006-05-10
Last Update Date:2019-11-04
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MO110189363L00000X, 363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
IL$$$$$$$$$Medicaid
MO814724748Medicare PIN
MO814724740Medicare PIN
MO000081472Medicare ID - Type Unspecified
IL$$$$$$$$$001Medicaid
MO427545108Medicaid
P87710Medicare UPIN