Basic Information
| Provider Information | |||||||||
| NPI: | 1740348986 | ||||||||
| EntityType: | 1 | ||||||||
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| OrganizationName: | |||||||||
| LastName: | KIM | ||||||||
| FirstName: | GLORIA | ||||||||
| MiddleName: | S. | ||||||||
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| Credential: | CRNP | ||||||||
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| Mailing Information | |||||||||
| Address1: | 200 HYGEIA DR STE 2300 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 197132049 | ||||||||
| CountryCode: | US | ||||||||
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| Practice Location | |||||||||
| Address1: | 4735 OGLETOWN STANTON RD STE 1250 | ||||||||
| Address2: | |||||||||
| City: | NEWARK | ||||||||
| State: | DE | ||||||||
| PostalCode: | 19713 | ||||||||
| CountryCode: | US | ||||||||
| TelephoneNumber: | 3026230200 | ||||||||
| FaxNumber: | 3026230117 | ||||||||
| Other Information | |||||||||
| ProviderEnumerationDate: | 12/04/2006 | ||||||||
| LastUpdateDate: | 04/17/2019 | ||||||||
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| ProviderGenderCode: | F | ||||||||
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| IsSoleProprietor: | N | ||||||||
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Taxonomy Information
| Taxonomy | License | State | Switch | TaxonomyGroup | TaxonomyType | TaxonomyClass | SubSpecialty | 163W00000X | L1-0020432 | DE | N | Nursing Service Providers | Registered Nurse | 363LF0000X | LG-0000396 | DE | Y | Physician Assistants & Advanced Practice Nursing Providers | Nurse Practitioner | Family |
ID Information
| ID | Type | State | Issuer | Description | 1740348986 | 05 | DE | MEDICAID | 162440 | 01 | DE | MEDICARE GROUP NUMBER | OTHER |