Provider Demographics
NPI:1861109555
Name:KIM, SAEBOM (APRN)
Entity type:Individual
Prefix:
First Name:SAEBOM
Middle Name:
Last Name:KIM
Suffix:
Gender:F
Credentials:APRN
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:112 ESSEX AVE APT 15A
Mailing Address - Street 2:
Mailing Address - City:ALTAMONTE SPRINGS
Mailing Address - State:FL
Mailing Address - Zip Code:32701-4516
Mailing Address - Country:US
Mailing Address - Phone:971-803-8383
Mailing Address - Fax:
Practice Address - Street 1:2170 W STATE ROAD 434 STE 190
Practice Address - Street 2:
Practice Address - City:LONGWOOD
Practice Address - State:FL
Practice Address - Zip Code:32779-4976
Practice Address - Country:US
Practice Address - Phone:407-990-1921
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-11-01
Last Update Date:2023-07-28
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
FL11022905363L00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363L00000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse Practitioner