Provider Demographics
NPI:1881086866
Name:SONG, YEONSU (RN, FNP-C)
Entity type:Individual
Prefix:
First Name:YEONSU
Middle Name:
Last Name:SONG
Suffix:
Gender:F
Credentials:RN, FNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:5690 CONISTON WAY
Mailing Address - Street 2:
Mailing Address - City:SAN JOSE
Mailing Address - State:CA
Mailing Address - Zip Code:95118-3517
Mailing Address - Country:US
Mailing Address - Phone:
Mailing Address - Fax:
Practice Address - Street 1:5690 CONISTON WAY
Practice Address - Street 2:
Practice Address - City:SAN JOSE
Practice Address - State:CA
Practice Address - Zip Code:95118-3517
Practice Address - Country:US
Practice Address - Phone:415-318-9173
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2015-02-27
Last Update Date:2017-02-05
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA653587163W00000X
CA95000459363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163W00000XNursing Service ProvidersRegistered Nurse