Basic Information
| Provider Information | |||||||||
| NPI: | 1184159428 | ||||||||
| EntityType: | 1 | ||||||||
| ReplacementNPI: | |||||||||
| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | GRACE | ||||||||
| MiddleName: | SUNG HYE | ||||||||
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| OtherLastName: | KIM | ||||||||
| OtherFirstName: | SUNG HYE | ||||||||
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| OtherLastNameType: | 1 | ||||||||
| Mailing Information | |||||||||
| Address1: | 720 W OAK ST STE 201 | ||||||||
| Address2: | |||||||||
| City: | KISSIMMEE | ||||||||
| State: | FL | ||||||||
| PostalCode: | 347414998 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 4075182703 | ||||||||
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| Practice Location | |||||||||
| Address1: | 216 MICHIGAN AVE NE | ||||||||
| Address2: | |||||||||
| City: | WASHINGTON | ||||||||
| State: | DC | ||||||||
| PostalCode: | 200171095 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 2028776333 | ||||||||
| FaxNumber: | |||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 04/24/2017 | ||||||||
| LastUpdateDate: | 07/20/2022 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | Y | ||||||||
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| NPICertificationDate: | 07/20/2022 | ||||||||
Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 390200000X | N | Student, Health Care | Student in an Organized Health Care Education/Training Program | 2084P0800X | MD210001978 | DC | Y | Allopathic & Osteopathic Physicians | Psychiatry & Neurology | Psychiatry |
No ID Information.