Provider Demographics
NPI:1912492216
Name:KWON, JI YEON (NP)
Entity Type:Individual
Prefix:
First Name:JI
Middle Name:YEON
Last Name:KWON
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 1:9300 VALLEY CHILDRENS PL # GE07
Mailing Address - Street 2:
Mailing Address - City:MADERA
Mailing Address - State:CA
Mailing Address - Zip Code:93636-8762
Mailing Address - Country:US
Mailing Address - Phone:559-353-6277
Mailing Address - Fax:559-353-7195
Practice Address - Street 1:9300 VALLEY CHILDRENS PL # GE07
Practice Address - Street 2:
Practice Address - City:MADERA
Practice Address - State:CA
Practice Address - Zip Code:93636
Practice Address - Country:US
Practice Address - Phone:559-353-6277
Practice Address - Fax:559-353-7195
Is Sole Proprietor?:No
Enumeration Date:2018-06-28
Last Update Date:2018-07-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA821931163W00000X
CA95009482363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner
No163W00000XNursing Service ProvidersRegistered Nurse