Provider Demographics
NPI:1629892815
Name:KIM, KYUNG
Entity type:Individual
Prefix:
First Name:KYUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:1135 W CHELTENHAM AVE STE 205
Mailing Address - Street 2:
Mailing Address - City:ELKINS PARK
Mailing Address - State:PA
Mailing Address - Zip Code:19027-3008
Mailing Address - Country:US
Mailing Address - Phone:215-260-5828
Mailing Address - Fax:215-635-7501
Practice Address - Street 1:1135 W CHELTENHAM AVE STE 205
Practice Address - Street 2:
Practice Address - City:ELKINS PARK
Practice Address - State:PA
Practice Address - Zip Code:19027-3008
Practice Address - Country:US
Practice Address - Phone:215-635-7500
Practice Address - Fax:215-635-7501
Is Sole Proprietor?:Yes
Enumeration Date:2024-11-13
Last Update Date:2024-11-13
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
PA458839171400000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171400000XOther Service ProvidersHealth & Wellness Coach