Provider Demographics
NPI:1912453705
Name:KIM, MIJUNG (NURSE PRACTITIONER)
Entity Type:Individual
Prefix:
First Name:MIJUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:NURSE PRACTITIONER
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:10317 HORSEBACK RIDGE AVE
Mailing Address - Street 2:
Mailing Address - City:LAS VEGAS
Mailing Address - State:NV
Mailing Address - Zip Code:89144-6867
Mailing Address - Country:US
Mailing Address - Phone:702-406-1312
Mailing Address - Fax:
Practice Address - Street 1:5400 S RAINBOW BLVD
Practice Address - Street 2:
Practice Address - City:LAS VEGAS
Practice Address - State:NV
Practice Address - Zip Code:89118-1859
Practice Address - Country:US
Practice Address - Phone:702-853-3000
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2016-08-31
Last Update Date:2016-08-31
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
NVAPRN002293363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner