Provider Demographics
NPI:1003462722
Name:PARK, CAITLYN JEEIN
Entity Type:Individual
Prefix:
First Name:CAITLYN
Middle Name:JEEIN
Last Name:PARK
Suffix:
Gender:F
Credentials:
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:7212 ORANGETHORPE AVE STE 9A
Mailing Address - Street 2:
Mailing Address - City:BUENA PARK
Mailing Address - State:CA
Mailing Address - Zip Code:90621-4668
Mailing Address - Country:US
Mailing Address - Phone:714-503-6550
Mailing Address - Fax:
Practice Address - Street 1:7212 ORANGETHORPE AVE STE 9A
Practice Address - Street 2:
Practice Address - City:BUENA PARK
Practice Address - State:CA
Practice Address - Zip Code:90621-4668
Practice Address - Country:US
Practice Address - Phone:714-503-6550
Practice Address - Fax:
Is Sole Proprietor?:No
Enumeration Date:2019-08-18
Last Update Date:2021-07-01
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
CA95160347163WC0200X
CA95017087363LF0000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes363LF0000XPhysician Assistants & Advanced Practice Nursing ProvidersNurse PractitionerFamily
No163WC0200XNursing Service ProvidersRegistered NurseCritical Care Medicine