Provider Demographics
NPI:1023742756
Name:KIM, JIYEON (NP)
Entity type:Individual
Prefix:
First Name:JIYEON
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:NP
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
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Other - Credentials:
Mailing Address - Street 1:1270 GARDEN CITY RD APT 455
Mailing Address - Street 2:
Mailing Address - City:EAST LANSING
Mailing Address - State:MI
Mailing Address - Zip Code:48823-6045
Mailing Address - Country:US
Mailing Address - Phone:517-899-4816
Mailing Address - Fax:
Practice Address - Street 1:2380 CEDAR ST STE 100
Practice Address - Street 2:
Practice Address - City:HOLT
Practice Address - State:MI
Practice Address - Zip Code:48842-2210
Practice Address - Country:US
Practice Address - Phone:517-742-4900
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2022-07-09
Last Update Date:2022-07-09
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MI4704383913363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner