Provider Demographics
NPI:1043253594
Name:PARKE, MARY C (LD/N)
Entity Type:Individual
Prefix:MS
First Name:MARY
Middle Name:C
Last Name:PARKE
Suffix:
Gender:F
Credentials:LD/N
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:515 W 6TH ST
Mailing Address - Street 2:MC #24
Mailing Address - City:JACKSONVILLE
Mailing Address - State:FL
Mailing Address - Zip Code:32206-4324
Mailing Address - Country:US
Mailing Address - Phone:904-665-2410
Mailing Address - Fax:904-630-3316
Practice Address - Street 1:900 UNIVERSITY BLVD N
Practice Address - Street 2:
Practice Address - City:JACKSONVILLE
Practice Address - State:FL
Practice Address - Zip Code:32211-9203
Practice Address - Country:US
Practice Address - Phone:904-630-3290
Practice Address - Fax:904-745-3099
Is Sole Proprietor?:Not Answered
Enumeration Date:2006-06-13
Last Update Date:2007-07-08
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
133N00000X
FLND369133V00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Not Answered133N00000XDietary & Nutritional Service ProvidersNutritionist
Not Answered133V00000XDietary & Nutritional Service ProvidersDietitian, Registered
Provider Identifiers
StateIdentifier IDID TypeIssuer
FLE8297ZMedicare ID - Type Unspecified