Provider Demographics
NPI:1912089244
Name:KIM, KELLY H C (NP)
Entity Type:Individual
Prefix:
First Name:KELLY
Middle Name:H C
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 1:5700 CLEVELAND ST
Mailing Address - Street 2:SUITE 228
Mailing Address - City:VIRGINIA BEACH
Mailing Address - State:VA
Mailing Address - Zip Code:23462-1752
Mailing Address - Country:US
Mailing Address - Phone:757-499-2825
Mailing Address - Fax:
Practice Address - Street 1:1708 OLD DONATION PKWY
Practice Address - Street 2:
Practice Address - City:VIRGINIA BEACH
Practice Address - State:VA
Practice Address - Zip Code:23454-3064
Practice Address - Country:US
Practice Address - Phone:757-395-5300
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2006-10-19
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0001199919363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
Provider Identifiers
StateIdentifier IDID TypeIssuer
VA0001199919OtherSTATE RN LICENSE