Provider Demographics
NPI:1679125629
Name:KIM, KIRYOUNG (AGNP-C)
Entity type:Individual
Prefix:
First Name:KIRYOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:AGNP-C
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:43 TENBY CT
Mailing Address - Street 2:
Mailing Address - City:LUTHERVILLE TIMONIUM
Mailing Address - State:MD
Mailing Address - Zip Code:21093-1873
Mailing Address - Country:US
Mailing Address - Phone:857-225-2031
Mailing Address - Fax:
Practice Address - Street 1:401 N BROADWAY ST
Practice Address - Street 2:
Practice Address - City:BALTIMORE
Practice Address - State:MD
Practice Address - Zip Code:21287-0019
Practice Address - Country:US
Practice Address - Phone:410-614-3850
Practice Address - Fax:410-614-4501
Is Sole Proprietor?:No
Enumeration Date:2019-07-10
Last Update Date:2019-11-12
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
MDR214235363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner