Provider Demographics
NPI:1548974892
Name:KIM, MIKYOUNG (VA)
Entity type:Individual
Prefix:
First Name:MIKYOUNG
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:VA
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:4393 POPLAR TREE CT
Mailing Address - Street 2:
Mailing Address - City:CHANTILLY
Mailing Address - State:VA
Mailing Address - Zip Code:20151-2523
Mailing Address - Country:US
Mailing Address - Phone:240-477-2979
Mailing Address - Fax:
Practice Address - Street 1:1980 GALLOWS RD
Practice Address - Street 2:
Practice Address - City:VIENNA
Practice Address - State:VA
Practice Address - Zip Code:22182-3913
Practice Address - Country:US
Practice Address - Phone:703-323-5691
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2023-01-11
Last Update Date:2023-01-11
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
VA0121001029171100000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes171100000XOther Service ProvidersAcupuncturist