Provider Demographics
NPI:1023841947
Name:KWON-SONG, ALICE (NP)
Entity type:Individual
Prefix:
First Name:ALICE
Middle Name:
Last Name:KWON-SONG
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 1:11052 LINDA LN APT B
Mailing Address - Street 2:
Mailing Address - City:GARDEN GROVE
Mailing Address - State:CA
Mailing Address - Zip Code:92840-5216
Mailing Address - Country:US
Mailing Address - Phone:213-800-1947
Mailing Address - Fax:
Practice Address - Street 1:15825 LAGUNA CANYON RD STE 104
Practice Address - Street 2:
Practice Address - City:IRVINE
Practice Address - State:CA
Practice Address - Zip Code:92618-2126
Practice Address - Country:US
Practice Address - Phone:949-585-9870
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2024-08-26
Last Update Date:2024-08-26
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95030728363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner